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NEUROPSYCHIATRY 
AND  THE  WAR 


•I 


\ 


A  BlBLIOGRAPin    \MTH  ABSTRACTS 


SUPPLEMENT  I 
October  1918 


PREPARED  BY 

JVIiVBEL  WEBSTER  BROWN 

AN,  THE  NATIONAL  COMMITTEE  FOR  MEN1  \ 


i-;l)Itei)  by 
FRANKWOOD  E.  WIIXIAMg,  ^r    I) 

ASSOCIATE  MEDICAL  DIRECTOR 


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w  Alt  vvuiuv  LuAJjvunicj': 

I  ni  lO.NAL  COMMITTEE  FOR  MENTAL  Jii^. 

60  UNION  SQUARE.  NEW  YORK  CITY 


r^e. 


Columljia  Winibtviit^s  -p'ol ^ 
in  tiie  Citp  of  ^cto  l^orfe 


CoUess  of  $i)p£itcian£(  antr  ^urgeonse 


^titvmtt  l^ibrarp 


NEUROPSYCHIATRY 
AND  THE  WAR 

A  Bibliography  with  Abstracts 

SUPPLEMENT  I 

October  1918 


PREPARED  BY 

MABEL  WEBSTER  BROWN 

LIBRARIAN.  THE  NATIONAL  COMMITTEE  FOR  MENTAL  HYGIENE 


EDITED  BY 

FRANKWOOD  E.  WILLIAMS,  M.  D. 

A3S0CLA.TE  MEDICAL  DIRECTOR 
THE  NATIONAL  COMMITTEE  FOR  MENTAL  HYGIENE 


WAR  WORK  COMMITTEE 

THE  NATIONAL  COMMITTEE  FOR  MENTAL  HYGIENE,  INC. 

50  UNION  SQUARE,  NEW  YORK  CITY 

1918 


PREFACE 

The  literature  of  military  neuropsychiatry  has  become  so  volimiinous  since  the 
outbreak  of  the  war  that  it  was  found  impossible  to  include,  without  serious  delay 
in  publication,  abstracts  of  all  important  books  and  articles  on  this  subject  in 
the  original  volume,  "Neuropsychiatry  and  the  War."  For  this  reason  the 
War  Work  Committee  of  the  National  Committee  for  Mental  Hygiene  has  issued 
Supplement  I,  which  contains  as  much  of  this  omitted  material,  together  with  part 
of  the  more  recent  literature  on  the  subject  published  since  the  original  volume 
was  issued,  as  there  was  time  to  prepare  in  the  three  months  after  the  publication 
of  "Neuropsychiatry  and  the  War."  Owing  to  irregularity  of  receipt  of  foreign 
periodicals,  difficulties  in  securing  translators,  and  other  obstacles,  the  amount 
of  literature  of  many  of  the  European  countries  abstracted  in  Supplement  I  is 
very  scant.  It  is  the  hope  of  the  War  W^ork  Committee  that  it  may  be  possible 
to  make  accessible  to  date  this  omitted  material,  together  with  the  current 
literature  on  the  subject,  by  publishing  quarterly  bibliographies  as  additional 
supplements  to  "Neuropsychiatry  and  the  War."  Any  future  lists  will  be  as 
inclusive  as  possible,  but  only  material  of  special  interest  will  be  abstracted. 
In  order  to  indicate,  however,  the  scope  of  each  book  or  article  listed,  a 
descriptive  annotation  will  accompany  every  entry.  These  supplements,  if 
issued,  will  be  distributed  free  to  psychiatrists  and  neurologists  of  the  Medical 
Corps,  and  to  libraries  and  institutions  where  the  publication  can  be  used  to 
advantage. 


CONTENTS 

PAGE 

British  Literature 7-15 

French  Literature 17—26 

German  Literature 27—51 

Italian  Literature 53-57 

Literature  of  the  Netherlands 59-62 

Russian  Literature 63-65 

Scandinavian  Literature 67-69 

Literature  of  the  United  States 71-111 


BRITISH  LITERATURE 

Periodicals  Abstracted 
British  Medical  Journal,  London 
Lancet,  London 
Practitioner,  London 
Recalled  to  Life,  London 


BRITISH  LITERATURE 

Maitland,  E.  P.,  and  Campbell,  Kenneth.    Case  of  Temporary  Blind- 
ness.   Brit.  med.  j.,  Sept.  15,  1917,  p.  360 

A  sergeant,  aged  49,  was  admitted  to  hospital  with  a  temperature  of  101.2°,  and 
bUnd.  He  complained  of  some  headache.  Both  fundi  were  healthy,  the  media 
were  clear,  and  no  thickening  of  the  retinal  arteries  could  be  seen.  The  tem- 
perature slowly  fell  to  normal  in  eight  days,  when  pari  passu  with  the  reduction 
of  temperature  his  vision  began  to  improve,  and  fourteen  days  after  admission 
he  could  see  well  enough  to  read  a  newspaper.     He  later  returned  to  duty. 

The  usual  causes  of  blindness  unconnected  with  visible  eye  changes  are  hysteria, 
uremia,  and  acute  retrobulbar  neuritis.  The  case  bore  some  relation  to  the  last, 
but  the  pupils  were  undilated  and  normal  in  action,  there  was  no  pain  on  move- 
ment of  the  eyes,  nor  pain  on  pressure  applied  over  the  globes. 

The  case  was  considered  to  be  due  to  some  toxic  condition  of  the  blood,  which 
caused  either  anesthesia  of  the  rods  and  cones  of  the  retina,  or  of  the  neurons  of 
the  visual  cortical  centres. — A.  Ninian  Bruce,  Rev.  of  neurology  and  psychiatry 
15:332,Aug.-Sept.  1917. 

Green,  Edith  M.  N.    Blood  Pressure  and  Surface  Temperature  in  no 
Cases  of  Shell  Shock.    Lancet,  Lond.,  Sept.  22,  1917,  p.  45^57 

Green  presents  her  observations  on  blood  pressure  and  its  relation  to  the 
physical  condition  of  patients  in  the  British  Army. 

It  was  found  that  55  men  showed  on  admission  a  pressure  below  120  mm.Hg., 
and  of  these  25  were  between  88  and  110.  These  were  the  severe  cases  of  shell 
shock.  Of  the  other  55,  28  were  between  130  and  150  mm.  Hg.,  and  27  between 
120  and  130.  Of  those  above  130  only  4  were  severe  cases.  With  the  exception 
of  8  men,  all  showed  subnormal  surface  temperature  varying  from  18°  to  31.5°C. 
The  temperature  was  taken  in  the  hand  with  a  surface  temperature  thermometer, 
the  temperature  of  the  air  and  a  healthy  control  being  noted  at  the  same  time. 

All  of  the  cases  with  a  very  low  blood  pressure  were  suffering  from  dreams  which 
woke  them  in  a  state  of  terror,  sweating,  and  trembling.  Their  hands  were 
dusky  and  clammy,  and  most  of  them  had  a  tremor.  They  showed  a  marked 
fatiguability  and  irritability;  most  of  them  were  depressed  and  showed  a  great 
lack  of  self-confidence  and  initiative;  all  suffered  from  headache.  On  admission 
nearly  all  had  dilated  pupils. 

An  improvement  in  the  general  condition  was  coupled  with  a  gradual  rise  of 
pressure.  At  the  same  time  the  dreams  became  less  terrifying  and  there  were 
fewer  signs  of  fear.  In  some  cases  which  had  shown  a  return  of  symptoms — 
such  as  nightmares,  tremors,  headaches,  or  had  some  cause  for  considerable 
worry  — it  was  found  that  there  was  a  drop  in  blood  pressure  at  the  same  time. 
In  most  cases  there  was  a  rise  of  surface  temperature  as  the  general  condition 
improved,  though  any  subsequent  fall  in  surface  temperature  or  blood  pressure 
did  not  always  coincide.  a*.  ISSifin.tj*     k>*j 

No  case  showed  any  organic  lesion,  and  the  urine  was  normal. 

As  a  gradual  rise  in  blood  pressure  was  found  to  coincide  with  general  improve- 
ment in  condition,  pituitary  and  thyroid  extracts  were  given  in  order  to  see 
whether  a  general  improvement  could  be  obtained  more  quickly. 

An  interesting  point  was  the  almost  constant  relationship  between  the  low 
blood  pressure  and  terrifying  dreams.  It  seems  as  though  the  vaso-motor  dis- 
turbance which  was  produced  at  the  time  of  the  shock  was  rendered  more  or  less 

9 


10 

permanent  by  the  constant  repetition  in  dreams  of  the  former  terrifying  experi- 
ences. At  the  same  time  the  low  blood  pressure  caused  a  cerebral  anaemia  and 
lessened  mental  and  physical  activity,  wliich  prevented  the  man  from  throwing 
off  the  effects  of  his  imagination — thus  a  vicious  circle  being  produced.  A 
gradual  or  rapid  rise  of  blood  pressure  in  nearly  every  case  was  accompanied 
by  a  change  in  the  character  of  the  dreams,  the  terror  element  being  less  marked. 
—J.  B.  H.,  Bost.  med.  and  surg.  j.  173:  vii,  x,  Feb.  9,  1918. 

Collie,  Sir  John.  Management  of  Neurasthenia  and  Allied  Disorders 
Contracted  in  the  Army;  Lecture  Delivered  at  the  Royal  Institute 
of  Public  Health,  June  1917.  Recalled  to  life,  Lond.,  no.  2, 
p.  234-53,  Sept.  1917.    Also  in  Mental  hygiene  2 :  1-18,  Jan.  1918 

That  the  war  in  Europe  has  been  responsible  for  a  large  number  of  cases  of 
functional  nervous  disease  can  scarcely  be  a  matter  for  surprise  to  members  of 
the  medical  profession.  For  some  considerable  time  the  tendency  to  neurotic 
manifestations  has  been  on  the  increase  among  the  male  population  of  all  highly 
civilized  and  industrial  countries,  and  when  an  individual  of  this  type  has  been 
subjected  to  the  added  stress  and  strain  of  modern  warfare  it  is  not  surprising  that 
sooner  or  later  he  should  break  down  under  the  excessive  pressure. 

Col.  Sir  John  ColUe  delivered  in  London  some  time  ago  an  address  on  this 
subject.  He  pointed  out  that  approximately  there  were  34,000  men  in  Great 
Britain  who  were  drawing  pensions  because  of  their  inability  to  serve  on  account 
of  some  functional  nervous  disease.  Such  men  were  by  no  means  necessarily 
cowards,  indeed  many  of  the  34,000  had  distinguished  themselves  by  signal  acts 
of  bravery  and  when  seemingly  recovered  many  had  expressed  a  wish  to  return  to 
the  front — were  impelled  thereto  by  a  sense  of  duty.  Of  course  they  could  not 
go  because  they  were  temperamentally  and  neuropotentially  unfit  for  the  work. 
The  time  for  preventing  these  nervous  breakdowns  is,  if  possible,  before  the  ac- 
ceptance of  the  man  in  the  army.  There  are  a  large  number  of  men  apparently 
physically  fit  who  exhibit  no  symptoms  which  would  justify  the  medical  examiner 
in  rejecting  them,  and  who  yet  will  "crack"  under  the  nerve-racking  and  emo- 
tion-straining experience  of  war  as  it  is  waged  to-day.  It  has  been  announced 
recently  that  the  Medical  Department  of  the  U.  S.  Army  has  decided  to  extend 
its  psychological  examination  to  all  enlisted  men  and  to  all  newly  appointed 
officers  of  the  army.  The  extension  of  this  form  of  examination  is  due  to  the 
success  which  has  attended  the  experiment  of  psychological  examination  made 
at  Camps  Lee  and  Devens.  The  purposes  of  the  tests  as  outlined  by  Major 
Robert  M.  Yerkes  in  charge  of  the  section  of  psychology  of  the  surgeon  general's 
office,  are  as  follows:  (1)  To  aid  in  segregating  and  eliminating  the  mentally  in- 
competent. (2)  To  classify  men  according  to  their  mental  capacity.  (3)  To 
assist  in  selecting  competent  men  for  responsible  positions.  This  decision  of  the 
War  Department  is  a  step  in  the  right  direction,  and  may  aid  in  solving  the 
problem  of  the  neurasthenic  drafted  man,  although  there  is  little  or  no  relation 
between  mental  deficiency  and  neurasthenia.  The  existence  of  an  obvious 
tendency  to  functional  nervous  disease  should  be  easily  detected  by  a  careful 
examiner,  but  it  is  extremely  difficult,  in  fact  impossible  in  the  majority  of  in- 
stances, to  diagnose  a  simple  predisposition  to  neurasthenia.  Therefore  a  large 
number  of  cases  of  shock  will  continue  to  be  returned  from  the  front  and  the 
object  must  be  to  treat  these  as  efficiently  as  possible. 

Sir  John  Collie,  in  the  lecture  above  mentioned,  says  that  medical  treatment  is 
of  no  real  value  unless  the  medical  men  have  confidence  in  themselves  and  can  com- 
mandeer the  confidence  of  the  patient.  Infinite  patience,  common  sense  at  every 
turn,  and  real,  but  thoroughly  disguised  sympathy  are  essential  in  those  who 
undertake  the  care  of  such  cases.  Massage,  electricity,  persuasion,  occupation, 
light,  graduated  work,  fresh  air,  good  wholesome  food,  and  above  all  a  healthy 


11 

environment  are  essential  adjuncts.  The  psychotherapeutic  method  of  treat- 
ment has  been  found  by  experience  to  be  wonderfully  effective  provided  only 
that  it  is  in  the  right  hands.  Nothing  retards  recovery  so  much  as  the  flying 
visits  of  unthinking  but  kindly  intentioned  philanthropic  lady  visitors.  Per- 
suasive conversation  should  be  systematically  arranged  for,  in  which  the  patient 
and  doctor  can  have  quiet  talks,  so  that  the  man  is  led  by  tact  and  guarded  sym- 
pathy to  lay  bare,  what  is,  as  it  were,  at  the  back  of  his  mind.  Nothing  in  the 
nature  of  psychoanalysis,  however,  is  recommended.  Collie's  experience  is  that 
it  is  better  that  aU  patients  should  be  isolated  dm-ing  the  early  part  of  their  treat- 
ment. The  calm  restfulness  of  soUtude  has  a  peculiar  effect  in  allaying  irritabil- 
ity, and  strange  as  it  may  appear,  prevents  morbid  introspection.  Isolation  is 
not  solitary  confinement;  a  nurse  is  in  frequent  attendance.  The  short  initial 
stage  of  isolation  enhances  the  value  of  the  suggestion  of  rapid  recovery  practised 
by  the  physician  and  nurses.  Electrical  treatment  for  these  cases  is  of  value, 
but  the  stoutest  advocates  of  this  method  will  not  deny  that  the  effect  is  inti- 
mately associated  with  the  mysteriousness  of  the  electric  current.  There  is  one 
proviso  to  make  with  regard  to  all  treatment  and  that  is,  unless  the  patient  de- 
sires to  get  well  no  treatment  can  cure  him. — Med.  rec.  93:  460-61,  March  16, 
1918. 

Turner,  William  Aldren.    Hospital  Treatment  of  Shell  Shock.    Re- 
called to  life,  Lond.,  no.  2,  p.  251-53,  Sept.  1917 

In  Recalled  to  Life,  No.  2,  is  an  address  by  Lieut.-Col.  Aldren  Turner,  C.B.M.D., 
in  which  he  discusses  the  principles  of  the  management  of  the  shell-shocked 
and  neurasthenic  soldiers  in  the  special  military  hospitals.  These  principles, 
four  in  number,  were  laid  down  early  in  the  war,  but  they  were  subject  to  modifi- 
cation as  our  knowledge  of  these  patients  and  of  their  disabilities  became  better 
known  and  understood.  The  first  principle  was  segregation.  For  the  most  part 
the  neurasthenic  soldiers  had  been  treated  in  institutions  specially  set  apart  for 
the  purpose  under  the  care  of  medical  officers  specially  qualified  to  treat  them. 
The  adverse  criticisms  which  were  brought  forward  in  opposition  to  segregation 
in  the  early  months  of  the  war  had  not  been  justified.  On  the  contrary,  its 
usefulness  had  been  strengthened  and  extended  by  experience.  These  patients 
did  not  imitate  each  other,  or  in  other  ways  react  harmfully  upon  each  other. 
On  the  other  hand,  it  has  been  found  that  when  placed  in  the  general  wards  of  a 
hospital,  the  sufferer  from  shell  shock  not  infrequently  was  the  butt  of  the  other 
patients,  who  were  unsympathetic  and  disposed  to  regard  as  trivial  the  tremors, 
stuttering  speech,  unnatural  gait,  and  other  symptoms  which  characterized  so 
many  cases  of  shell  shock.  The  admixture  of  these  patients,  as  had  been  sug- 
gested, with  cheery  companions  suffering  from  non-nervous  disabilities,  might 
even  be  undesirable. 

The  second  principle  was  to  give  the  medical  officers  liberty  to  treat  their 
neurasthenic  patients  along  sucli  lines  as  they  considered  desirable  and  wliich 
experience  had  shown  to  be  of  therapeutic  value.  There  was  no  disorder  to 
which  the  axiom  "treat  the  patient  and  not  the  disease"  applied  with  greater 
directness  than  to  neurasthenia.  This  liberty  of  action  was  very  necessary 
when  they  considered  the  different  types  of  neuroses  and  psychoses  which  were 
admitted  to  the  military  hospitals  under  the  gjiise  of  shell  shock.  Cases  of 
exhaustion  recjuired  rest  in  bed;  paralytic  cases  required  exercises  and  reeduca- 
tion of  the  movements  of  the  paralyze<l  limbs.  The  simpler  forms  of  anxiety 
needed  reassuring  and  explanation  of  the  origin  of  their  fears.  The  terrifying 
dreams  which  disturlx-d  the  sleep  of  so  many  men  suffering  from  shell  shock 
required  to  be  analyzed  and  explained.  The  dreads  and  fears,  delusions  and 
hallucinations,  and  other  morbid  ideas  reciuired  to  be  searched,  investigated 
and  understood.  After  this  the  readjustment  of  the  patient's  mental  outlook 
towards  his  symptoms  required  to  be  taken  in  hand.     It  had  been  found  that  a 


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too  constant  and  too  frequent  use  of  massage,  of  electrical  applications,  of  baths, 
and  of  other  physical  methods  of  treatment  assiduously  practised  at  the  spas, 
tended  to  accentuate  rather  than  relieve  the  condition  for  which  they  were  used. 

The  third  principle  was  occupation.  Quite  a  number  of  cases  of  war  neuras- 
thenia and  genuine  shell  shock  in  the  early  stages  derived  great  benefit  from  a 
"rest  cure,"  but  it  had  become  increasingly  obvious,  with  more  experience 
and  knowledge  of  these  cases  and  their  causes,  that  rest  and  isolation  had  only  a 
limited  application.  The  best  results  were  obtained  by  a  judicious  combination 
of  a  suitable  psychotherapy  and  occupation,  mainly  of  an  outdoor  kind.  It  was 
useless  to  attempt  to  cure  by  work  alone,  a  man  whose  mind  was  depressed  by 
anxiety  and  forebodings  attributable  to  circumstances  which  he  did  not  under- 
stand; but  if  by  judiciously  selected  work  and  carefully  regulated  outdoor  occu- 
pation, liis  sleeplessness  was  mitigated  and  his  circulation  and  general  nutrition 
improved,  the  value  of  the  mental  therapeutics  was  enhanced  and  supplemented. 

The  fourth  principle  was  compensation.  It  was  recognized  early  in  the  war 
that  a  large  number  of  soldiers  who  suffered  from  shell  shock  and  nevirasthenia 
would  be  unfit  to  return  to  military  duty,  although  their  ability  to  carry  on 
their  civilian  work  after  discharge  would  not  be  more  than  temporarily  im- 
paired. As  it  had  been  recognized  for  a  long  time  that  some  forms  of  nervous 
disability  were  prone  to  exaggeration,  or  might  even  be  made  chronic  by  undue 
consideration,  it  was  determined  that  nothing  should  be  done  by  the  payment 
of  pensions  which  would  retard  or  prevent  the  recovery  of  soldiers  who  had  been 
disabled  from  nervous  breakdown.  It  was  thought,  therefore,  to  be  desirable 
to  recommend  the  granting  of  a  money  bonus,  in  place  of  a  pension  to  selected 
cases  of  neurasthenia  and  functional  nervous  disorder  occurring  amongst  sol- 
diers when  treatment  in  hospital  was  no  longer  necessary  and  the  patient  was 
unlikely  to  be  fit  for  further  military  service. — Med.  rec.  93:  726,  April  27,  1918. 

Viets,  Henry.    Shell-Shock;  a  Digest  of  the  English  Literature.    J.  of 
Amer.  med.  assoc.  69:  1779-86,  Nov.  24,  1917. 

The  author  reviews  the  English  medical  literature  of  shell-shock,  making 
frequent  quotations  from  the  authorities  to  whom  he  refers.  The  first  report 
of  cases  appeared  in  1915  under  the  term  of  "shell-shock."  The  symptoms 
are  varied,  covering  nearly  all  the  functional  and  hysterical  phenomena  de- 
scribed by  authors.  The  importance  of  the  problem  cannot  be  overemphasized 
and,  if  it  is  possible,  those  subject  to  the  disease  should  be  eliminated  from  among 
the  recruits  before  they  are  exposed  to  the  perils  of  trench  warfare.  The  neuro- 
pathology of  the  condition  has  been  best  studied  by  Mott.  In  the  fatal  cases, 
the  symptoms  of  shell-shock  resemble  those  of  the  gas  poisoning,  wliich  most 
neurologists  hold  cannot  alone  produce  shell-shock.  The  treatment  is  largely 
moral  as  well  as  physical  and  seems  to  have  been  well  worked  up  in  the  British 
hospita,Is.  The  writer  asks  in  conclusion:  "What  can  the  Medical  Corps  of  the 
United  States  Army  do  toward  the  prevention  of  shell-shock?  Obviously  it 
must  be  checked  at  the  recruiting  station  or  in  the  cantonment  camps  before  the 
men  leave  for  France.  There  ought  to  be  no  question  in  the  minds  of  the  medical 
officers  as  to  the  advisability  of  checking  this  condition  at  the  source,  for  no  one 
who  has  seen  the  results  of  modern  warfare  on  the  unstable  mind  can  do  otherwise 
than  urge  such  measures  with  utmost  vigor.  It  becomes  the  duty  of  each  medical 
examiner  to  weed  out  from  the  recruits  such  men  as  are  liable  to  shell-shock.  By 
so  doing  an  enormously  important  advance  will  be  made  in  our  army,  as  judged 
by  the  experiences  of  the  other  armies  of  the  Allies.  We  have  been  strongly 
advised  by  Osier  to  check  the  enlistment  of  the  neurasthenic.  It  is  obviously 
difficult  to  pick  him  from  the  crowd,  as  he  may  come  up  in  good  form,  and  be 
eager  to  go  overseas.  But  it  is  not  so  difficult' with  the  mentally  deficient,  the 
'queer  stick,'  the  'boob,'  and  the  butt  of  the  practical  jokers.  He  is  soon  ob- 
served by  both  officers  and  men,  and  if  one  singles  him  out  and  talks  with  him  for 


13 

five  or  ten  minutes,  one  ought  to  have  no  difficulty  in  deciding  his  fitness  for 
active  trench  warfare.  One  ought  also  to  look  ^-ith  especial  care  into  the  past 
history  of  the  depressed,  the  man  who  worries  unnecessarily,  the  self-conscious, 
the  shy,  the  high-strung,  excitable  man,  the  violent-tempered,  the  nervous,  the 
timorous,  the  easily  frightened,  or  the  neurotic  individual.  Any  or  all  of  them 
may  make  poor  first-line-trench  soldiers.  The  task  is  difficult,  but  that  in  itself 
should  not  prevent  us  from  trjdng.  What  an  advantage  it  would  be  to  our  army 
officers,  and  what  a  saving  of  Ufe  it  would  mean  to  our  men,  if  the  shell-shock 
patients  could  be  eUminated  from  our  forces  that  will  fight  overseas!  Such  a 
Utopia  is  probably  impossible,  but  I  feel  confident  that  careful  weeding  out  of  the 
mentally  unfit  will  certainly  greatly  reduce  the  numbers  of  shell-shock  cases  that 
are  boimd  to  appear  in  our  casualty  lists." — J.  nerv.  and  ment.  dis.  47: 146-47, 
Feb.  1918. 

Jones,  A.  Bassett,  and  Llewellyn,  Llewellyn  J.  Malingering,  or  the 
Simulation  of  Disease.*    Phil.,  Blakiston,  1917.    708  p. 

The  present  war  has  brought  to  the  front  a  subject  which  is  greatly  neglected 
in  peace  times.  To  be  sure,  prison  physicians,  psychiatrists,  and  insurance 
examiners  are  all  more  or  less  famiUar  with  malingerers,  but  now  that  the  world 
has  been  combed  for  soldiers,  and  these  exposed  to  terrific  strain,  we  find  whole- 
sale malingering.  Artificially  induced  abscesses,  sugar  added  to  the  urine,  soap- 
chewing,  convulsive  efforts,  these  are  commonplaces  in  the  big  armies,  and  have 
been  described  in  many  papers.  Jones  and  Llewellyn,  however,  have  undertaken 
a  monograph  on  the  subject  and  produced  an  admirable  work.  After  an  exhaus- 
tive study  of  the  subject  as  a  whole,  with  its  psychology  and  medico-legal  aspects, 
the  authors  go  into  great  detail  in  describing  malingering  in  its  relation  to  various 
systems  of  the  body;  this  part  of  the  book  is  systematic  and  thorough,  no  vague 
generalizations  are  indulged  in,  but  the  writers  are  specific  and  practical.  In 
short,  they  exemplify  their  owti  doctrine  that  a  diagnosis  of  malingering  must  not 
be  founded  on  incomplete  examination,  imperfect  observation,  or  hasty  in- 
ference. This  work  might  well  be  added  to  any  practitioner's  library;  to  the 
military  surgeon  it  is  invaluable. — Med.  rec.  93:  474,  March  16,  1918. 

Mott,  Frederick  W.  War  Psychoneurosis.  Lancet,  Lond.,  i :  127, 
Jan.  26,  1918 

While  admitting  that  from  commotion  or  prolonged  stress  of  war,  a  stable 
nervous  organization  may  develop  an  acquired  emotivity,  Mott  says  that  it 
seems  that  the  psychogenic  or  autosuggestive  factor,  acting  on  a  prewar  emotive 
brain,  is  the  chief  determining  cause  of  war  psychoneurosis,  and  the  neurotic 
patient's  protest  of  anxiety  lest  he  be  boarded  out  of  the  service,  or  not  allowed 
to  go  to  the  front,  is  really  in  many  cases  an  indication  of  an  exhausting  conflict 
which  has  been  going  on  continually  in  his  mind  between  the  self-conservative 
instinct  and  the  moral  obligation  of  duty  and  patriotism,  which  has  its  roots  in 
the  social  herd  instinct.— J.  A.  M.  A.  70:  1263,  April  27,  1918. 

Forster,  Frederick  C.  Management  of  Neurasthenia,  Psychasthenia, 
Shell-Shock  and  Allied  Conditions.  Practitioner,  Lond.,  100: 
85-90,  Jan.  1918 

In  the  Practitioner  for  January,  1918,  is  published  a  paper  on  the  management 
of  neurasthenia,  psychasthenia,  shell  shock,  and  allied  conditions,  by  Dr.  Fred- 
erick C.  Forster,  in  which  the  author  points  out  that  while  neurasthenia  may  be 
of  different  tj-pes  the  sufferers  nearly  always  have  in  common  certain  symptoms, 
the  most  prominent  being  depression,  lassitude,  often  combined  with  a  curious 
restlessness,  insomnia,  loss  of  power  of  concentration,  failure  of  memory,  abnor- 

*  Published  originally  in  London  by  William  Hcinemann,  1917. 


14 

mal  sensations  in  different  organs,  tremblings,  dragging  pains,  palpitation,  loss 
of  appetite,  and  loss  of  vitality.  This  is  a  true  word-picture  of  the  symptoms  of 
a  neurasthenic,  not  that  they  are  all  combined  in  one  sufferer,  but  they  are  the 
conspicuous  symptoms  that  are  apt  to  occur.  Worrying  over  his  complaints  and 
imaginary'  complaints  is  a  characteristic  feature  of  the  sufferer  from  neurasthenia. 
He  attaches  undue  importance  to  all  his  disagreeable  sensations,  and  is  espe- 
cially anxious  T\ath  regard  to  the  tachycardia,  which  is  a  frequent  accompaniment 
of  the  condition,  imagining  it  to  be  a  sure  indication  of  a  serious  heart  lesion. 

The  cure  of  a  neurasthenic  involves  infinite  patience  and  tact  on  the  part  of 
the  medical  attendant.  First  of  all,  in  treating  a  case  it  is  incumbent  on  the 
medical  man  to  make  a  correct  diagnosis,  and  definite  disease  of  any  organ  must 
be  eliminated  before  it  can  be  said  to  be  a  true  neurasthenia.  Assurance  must 
be  had  that  the  condition  is  not  owing  to  toxemia,  influenzal  or  gastrointestinal, 
for  the  depression  accompanying  or  following  a  toxemia  of  tliis  description  cannot 
be  labeled  or  treated  as  a  neurasthenia.  Forster  holds  that  the  keynote  of  the 
management,  a  term  he  uses  purposely  in  preference  to  treatment,  is  to  induce 
"self-forgetfulness,"  to  do  away  with  the  inertia,  to  improve  the  morale  by  en- 
com-aging  a  feehng  of  independence,  and  to  adjust  the  patient's  life  so  that 
petty  troubles  and  annoyances  take  their  subordinate  position,  whether  this  is 
achieved  by  some  wholesome  occupation,  by  drugs,  or  by  some  of  the  many 
other  methods  which  may  be  employed.  The  Weir-Mitchell  rest  cure  is  recom- 
mended, and  it  is  pointed  out  that,  apart  from  the  dieting,  the  chief  essential  is 
to  procure  sleep  for  the  patient.  As  for  drugs,  chloralamide  is  to  be  preferred 
to  either  paraldehyde  or  the  bromides,  and  for  the  general  excitation  mono- 
bromated camphor  with  conium  is  useful.  It  is  not  advisable,  however,  to 
prolong  the  Weir-Mitchell  treatment  after  the  acute  stage  has  passed  off. 

It  really  is  an  interest  in  life  that  such  people  need.  The  author  is  not  an 
advocate  of  drug  treatment.  Regarding  change  of  air,  scene,  and  climate, 
wliich  really  means  change  of  environment,  the  suggestion  is  put  forth  that  it  is 
not  always  possible  to  change  the  physical  environment,  yet  much,  verj'  much, 
can  be  acliieved  by  altering  the  mental  or  psychical  environment,  and  the  power 
of  creating  a  special  mental  environment  is  helpful  in  turning  what  is  repulsive 
into  what  attracts.  In  short,  in  neurasthenia  it  is  the  person,  rather  than  the 
disease,  that  demands  treatment.  Finally,  a  return  to  work  or  occupation  is 
likely  to  be  of  greater  benefit  by  far  than  rest  cures,  that  is  to  say,  in  a  large 
proportion  of  cases. — Med.  rec.  93:464-65,  March  16,  1918. 

Savage,  Sir  George  H.  Mental  War  Cripples.  Practitioner,  Lond., 
100 : 1-7,  Jan.  1918 
George  H.  Savage  is  of  the  opinion  that  a  very  large  number  of  soldiers  and 
sailors  will,  after  the  war,  be  found  more  or  less  crippled,  that  is,  unfit  to  per- 
form their  normal  and  accustomed  duties,  and  that  they  will  need  special  treat- 
ment and  in  some  cases  will  have  to  learn  fresh  work.  For  such  patients,  phy- 
sical or  mental  cripples,  he  believes  that  colonies  in  the  country  will  be  found  to 
be  the  most  beneficial.  It  will  have  to  be  considered  whether  such  colonies 
should  be  special  or  general.  His  own  opinion  is  that  for  epileptics  the  colony 
should  be  special,  but  that  for  other  nerve  disorders  a  union  with  sufferers  might 
be  found  useful,  as  drawing  the  patient  away  from  his  subjective  state  to  one  of 
more  active  objective  sympathy. — N.  Y.  med.  j.  107:472,  March  9,  1918. 

Wolfsohn,  Julian  M.     The  Predisposing  Factors  of  War  Psycho- 
neuroses.*    Lancet,  Lond.,  Feb.  2,  1918,  p.  177-80 

Julian  M.  Wolfsohn  finds  that  throughout  the  massive  literature  which  has 
sprung  up  within  the  past  three  years  one  reads  passing  references  mostly  to  the 

*  Practically  the  same  article  was  published  m  Journal  of  the  American  Medical  Asso- 
ciation 70:  303-08,  Feb.  2,  1918. 


15 

relation  of  the  symptoms  of  war  psychoneuroses  to  a  previous  neuro-potentially 
unsound  soldier;  most  authors  have  eHcited  an  inherited  or  acquired  neuropathy 
in  the  majority  of  patients  afflicted  with  shell  shock,  neurasthenia,  or  any  of  the 
neuroses  resulting  from  the  strain  of  the  war.  But  enough  actual  specific  data 
on  the  inherited  and  acquired  neurotic  factors  in  these  cases  have  not  been  pub- 
lished. Before  drawing  generalizations  on  this  subject,  one  should  try  to  answer 
some  of  the  following  pertinent  questions:  (1)  Of  what  kind  of  forbears  is  the 
patient  a  representative.^  (2)  What  is  the  personal  temperament  of  the  patient.' 
(3)  What  was  his  former  calling,  and  how  has  he  shouldered  his  responsibilities 
during  active  war  service.^  (4)  Do  acquired  war  psychoneuroses  occur,  and 
what  are  the  causes  thereof?  (5)  What  is  the  relation  of  the  last  "shock"  to  the 
production  of  the  war  neurosis.^  (6)  Why  do  not  all  soldiers  suffer  from  war 
neuroses?  Before  answering  any  of  these  questions  one  must  examine  all  avail- 
able data,  up  to  the  time  of  active  service,  and  also  the  actual  causes  and  cir- 
cumstances exciting  the  outbreak  of  the  neurosis,  realizing  that  every  individual's 
nervous  system  will  react  according  to  his  inherited  tendencies  superimposed  on 
the  effects  produced  by  environment.  Therefore  the  object  of  this  special  work 
is  to  make  an  intensive  study  of  the  causal  factors  of  war  neurosis  as  presented 
by  the  family  and  the  personal  histories  (up  to  the  time  of,  and  including  the 
cause  of,  disablement)  of  100  cases  of  war  psychoneuroses — viz.,  shell  shock, 
neurasthenia,  hysteria,  and  exhaustion.  Insane  cases  are  not  included  in  this 
paper.  As  a  control  100  cases  of  somatic  injuries  produced  in  the  firing-line — 
viz.,  enucleation  of  an  ej'e,  fracture  of  the  skull,  jaw,  femur,  amputations,  and 
wounds,  with  or  without  sepsis,  have  been  similarly  studied.  The  exhaustive 
history  in  most  of  the  cases  was  given  by  the  patient  himself.  In  some  cases 
the  help  of  the  wife  or  mother  was  necessitated  to  get  as  much  first-hand  avail- 
able data  as  possible.  From  this  study  of  100  cases  of  war  psychoneuroses  and 
100  cases  of  somatic  injuries  produced  in  the  firing  line  Wolfsohn  finds  he  can 
draw  the  following  conclusions:  Cases  of  war  neurosis  are  very  rarely  associated 
with  external  or  somatic  wounds.  The  vast  majority  of  the  psychoneurotic 
cases  studied  were  among  soldiers  who  had  a  neuropathic  or  psychopathic  soil. 
In  14  per  cent  of  these  cases  a  family  history  of  neurotic  or  psychotic  stigmata, 
including  insanity,  epilepsy,  alcoholism  and  nervousness,  was  obtained,  whilst  a 
previous  neuropathic  constitution  in  the  patient  liimsclf  was  present  in  72  per 
cent.  A  gradual  psychic  shock  from  long-continued  fear,  together  with  the 
sudden  change  from  quiet  peaceful  environment  to  the  extraordinary  stress  and 
strain  of  trench  fighting  is  the  chief  predisposing  cause  of  war  psychoneurosis  in 
soldiers  with  neuropathic  predisposition.  In  fact,  these  factors  may  be  the 
cause  of  the  neurosis  per  se.  The  history  of  the  individual  previous  to  enlistment 
has  an  influence  on  the  character  and  gravity  of  the  symptoms  of  the  neurosis. 
Acquired  neuroses  with  their  less  severe  symptoms  appeared  only  after  excessive 
fatigue,  with  the  concussion  from  the  high-explosive  detonation  acting  as  the 
exciting  factor.  On  the  other  hand,  in  the  same  abnormal  environment,  and 
with  the  same  powerful  factors  obtaining,  wounded  soldiers  do  not  suffer  from 
war  neuroses  except  in  rare  instances.  In  the  wounded  soldiers  stu<lied  no 
neuropathic  or  psychopathic  stigmata  occurred  in  the  family  history.  Previous 
neuropathic  tendencies  were  found  in  10  per  cent  of  these  patients  (controls),  all 
of  which  number  presented  mild  neurasthenic  symptoms.  Hysteric  manifesta- 
tions, such  as  monoplegia  in  a  wounded  limb,  are  occasionally  encountered  in 
injured  soldiers.— Med.  rec.  93:  382-83,  March  2,  1918. 


FRENCH  LITERATURE 

Periodicals  Abstracted 
Annales  de  Medicine,  Paris 
Archives  Medicales  Beiges,  Paris 
Bulletin  de  1' Academic  de  Medicine,  Paris 
Bulletin  de  la  Societe  des  Hopitaux,  Paris 
Paris  Medical 
Progres  Medical,  Paris 
Revue  Neurologique,  Paris 


FRENCH  LITERATURE 

Pitres,  A.,  and  Marchand,  L.  Observations  on  Concussion  Syndromes 
Simulating  Organic  Affections  of  tlie  Central  Nervous  System 
(Quelques  observations  de  syndromes  commotionnelles  simu- 
lantes  des  affections  organiques  du  systeme  nerveux  central) 
Rev.  neurol.,  Paris,  23:  298-311,  Nov.-Dec.  1916 

In  the  first  patient  a  meningitic  syndrome  developed  soon  after  shell  concus- 
sion; severe  headache,  retraction  of  the  head,  Kernig's  sign  and  unilateral  ptosis. 
The  spinal  fluid  had  a  yellow  color.  He  afterward  developed  a  mental  condition 
resembling  catatonic  dementia  prsecox.  Fourteen  months  after  the  injury  he 
was  reexamined  and  all  symptoms  were  absent  except  slight  weakness  of  the 
legs.  In  the  second  case  there  was  a  period  of  unconsciousness  following  the 
concussion,  mental  confusion,  memory  disturbance.  The  knee  and  Achilles 
jerks  were  lost.  Speech  was  tremulous  and  hesitant.  Except  for  the  per- 
sistence of  some  ideas  of  persecution,  the  patient  recovered  in  sixteen  months. 
The  third  patient  presented  a  cerebellar  syndrome  with  the  addition  of  some 
mental  disturbance.  The  case  simulating  multiple  sclerosis  had  lost  knee  and 
Achilles  jerks.  The  case  simulating  tabes  had  no  lightning  pains,  but  in  other 
respects  was  typical  (the  Wassermann  reaction  was  positive).  The  author 
draws  two  conclusions:  The  diagnosis  in  these  cases  is  difficult.  These  cases 
have  as  a  basis  an  organic  lesion.     They  are  not  hysterical  or  simulation. 

Alterations  in  speech  are  divided  into  three  classes:  mutism,  a  stammering 
speech,  and  a  high-pitched  voice  in  which  the  patient  speaks  rapidly  and  ir- 
regularly. 

Mental  childishness,  in  a  patient  twenty-one  years  old,  developed  as  a  condi- 
tion following  shell  shock.  He  talked  and  acted  like  a  child,  occupied  his  time 
sailing  boats,  etc.,  and  frequently  cried  in  a  diildish  way.  There  were  no  dis- 
orientation, no  hallucinations  and  the  neurologic  examination  was  negative. 

The  fundamental  question  in  the  determination  of  the  pension  allowance  in 
nervous  or  mental  cases  is  whether  or  not  the  condition  present  is  due  to  service 
in  the  war.  The  fatigue  and  emotions  of  war  may  act  as  a  determining  cause 
and  the  value  attaching  to  the  predisposing  cause,  whether  hereditary  or  ac- 
quired, is  the  same  as  in  civil  life. — J.  nerv.  and  ment.  dis.  47:  63-64,  Jan.  1918. 

Ferrand,  Jean.  Hystero-traumatism  witli  So-called  "Physiopathic" 
Syndrome  Cured  by  Re-education  (Hystero-traumatisme  avec 
syndrome  dit  "physiopathique"  gueri  par  la  reeducation)  Progres 
med.,  Paris,  33:  81-83,  Marcli  10,  1917 

Attempts  have  been  made  to  classify  the  numerous  forms  of  paralysis  resulting 
from  wounds  in  battle.  Some  are  due  to  direct  lesions  of  peripheral  nerves  and 
their  roots;  others  are  hystcrotraumatic  in  nature.  Between  these  two  extreme 
varieties  there  is  a  particular  clinical  type  which  must  be  isolated  from  others — 
paralysis  of  reflex  origin. 

Certain  neurologists  describe  a  form  of  paralysis  characterised  by  special 
trophic,  vaso-motor,  electric,  and  reflex  troubles  in  the  paralysed  limb,  such 
phemomena  being  sufficient  in  their  eyes  to  prove  the  organic  origin  of  the  paraly- 
sis, which  explains  their  therapeutic  failures.  They  infer  from  this  the  useless- 
ness  of  even  heroic  psycho-therapeutic  measures.  This  inference  would  seem 
to  be  somewhat  premature,  as  observations  on  a  case  in  point  go  to  prove  the 
contrary.     It  was  that  of  an  infantry  soldier  who,  in  May,  1915,  was  woimdcd  in 

19 


20 

the  right  calf.  Heahng  followed  a  normal  course,  and  was  completed  in  a  few 
'  weeks.  During  convalescence  he  began  to  walk  badly  owing  to  alleged  pain  in 
the  limb,  which  assumed  the  position  of  equinus  with  contracted  Achilles  tendon. 
A  surgeon,  believing  that  the  lesion  was  really  organic,  severed  the  tendon,  restor- 
ing mobility  to  the  foot,  which  could  now  be  easily  placed  flat  on  the  ground. 
He  could,  however,  walk  no  better  after  the  operation,  and,  although  the  equine 
phenomenon  could  no  longer  be  produced,  owing  to  section  of  the  tendon,  the 
leg  assumed  another  vicious  position,  being  semi-flexed  on  the  thigh  with  im- 
mobilisation of  the  knee-joint.  He  could  only  barely  put  his  foot  to  the  ground, 
and  was  extremely  lame,  walking  with  the  help  of  a  crutch.  Again  a  surgeon, 
never  suspecting  a  neuropathic  affection  in  the  case  of  a  wounded  man,  did  a 
tenotomy  of  the  flexor  tendons  of  the  leg,  putting  it  up  in  a  plaster  apparatus  to 
maintain  extension  of  the  limb.  The  result  was  satisfactory  only  to  a  slight 
-extent,  but  he  walked  without  a  crutch  when  he  was  sent  to  a  neurologic  centre 
in  December,  1916. 

He  walked  with  two  sticks,  the  right  leg  in  a  position  of  forced  extension  on  the 
thigh,  and  flexion  was  impossible.  The  first  care  was  to  seek  for  evidence  of  a 
lesion  of  the  terminal  branches  of  the  sciatic,  and  especially  of  the  internal  popliteal 
branch.  There  was  no  true  motor  paralysis,  but  relative  weakness  of  all  active 
movements.  All  passive  ones  were  possible  except  flexion  of  the  knee.  There 
was  no  sensory  trouble;  and  all  the  reflexes  were  normal,  a  little  stronger  perhaps 
on  the  affected  side.  Trophic  troubles  were  very  marked.  All  the  distal  part 
of  the  leg  was  oedematous,  cyanosed,  almost  a  violet  tint,  very  cold  as  com- 
pared with  the  sound  limb.  The  skin  was  thin,  attenuated,  and  the  toes  crossed 
each  other  to  some  extent.  In  the  whole  foot  and  lower  third  of  the  leg  there  was 
well-marked  muscular  hyperexcitabUity.  The  slightest  tap  on  the  muscles 
brought  on  violent  contractions,  and  even  dissociation  of  movements  which  are 
not  usually  independent  in  action,  such  as  adduction  of  the  great  toe,  or  abduction 
of  the  little  one.  In  a  word,  the  case  presented  all  the  troubles  attributed  to 
reflex  contractures  or  to  the  phenomena  called  "physiopathic". 

The  mental  state  was  pecuUar.  A  working  miner,  he  weeps  at  the  least  exam- 
ination, manifests  absolute  terror, at  the  slightest  touch  of  his  affected  leg,  and 
trembUngly  implores  one  to  cure  him. 

To  sum  up :  here  was  a  wounded  patient  with  a  paralysed  limb  and  contraction 
of  the  knee,  who  presented  all  the  signs  of  the  paralyses  called  "reflex",  who  has 
been  subjected  to  a  series  of  tentative  therapeutic  measures  which  have  failed; 
a  characteristic  type. 

As  to  treatment  the  patient  was  brought  into  our  re-education  ward,  and,  after 
having  for  a  considerable  time  been  subjected  to  fatigue  by  more  or  less  violent 
physical  exercises,  the  contracture  was,  as  it  were,  brutally  overcome.  After  half 
an  hour  of  passive  movements  of  flexion  and  extension  of  the  leg,  and  after  show- 
ing him  how  he  could  bend  and  straighten  his  limb,  he  was  induced  to  do  this  vol- 
untarily. These  active  movements  were  aided  and  sometimes  provoked  by  gal- 
vanic stimulation  of  painful  intensity.  In  the  end  he  was  able  to  walk  slowly, 
while  he  bent  both  knees  fully,  and,  after  a  treatment  lasting  about  two  and  a 
half  hours,  he  was  cured. 

The  case  was  a  particiJarly  bad  one,  for  surgical  immobilisation  had  caused 
intra-articular  adhesions  in  the  knee  which  it  was  necessary  to  rupture.  A  slight 
amount  of  hydrarthrosis  followed  next  morning,  but  a  few  days  later  he  walked 
like  any  normal  person. 

This,  though  a  remarkable  case,  is  not  a  solitary  instance  of  the  kind,  and  Dr. 
Ferrand  has  published  the  general  result  of  his  researches  on  the  subject.  The 
clinical  type  which  has  been  sought  to  be  created  does  not  seem  sufficiently 
differentiated.  We  need  only  cite  in  proof  the  successive  denominations  which 
have  been  given  it.  The  term  "reflex  contracture"  assumes  a  condition  which 
very  often  does  not  exist,  for  there  is  flaccidity  in  many  of  these  paralyses. 


21 

Moreover,  the  term  "reflex"  implies  a  pathogenic  idea,  which  is  already  aban- 
doned by  the  creators  of  the  clinical  type.  It  has  been  designated  a  "physio- 
pathic  disorder",  a  term  which  is  not  very  precise,  and  has  hardly  more  signi- 
ficance than  the  old  term  "functional".  In  the  minds  of  the  authors  this  term 
"physiopathic"  would  imply  the  idea  of  an  organic  lesion,  or  at  least  one  not 
functional  in  character.  And  the  syndrome  thus  created  is,  in  their  descriptions, 
opposed  not  to  an  organic,  but  to  an  hysterical  syndrome.  In  this  view  Dr. 
Ferrand  cannot  share. 

He  concludes  his  article  with  the  following  summary : 

(1)  Physiopathic  symptoms  exist,  but  they  do  not  constitute  an  independent 
clinical  syndrome.  Many  patients  presenting  these  special  symptoms,  separate 
or  combined,  are  cases  of  organic  affections  with  lesions  of  peripheral  nerves; 
moreover,  direct  and  not  reflex. 

(2)  There  is  but  Uttle  relation  between  the  reflex  lesions  described  by  Charcot 
as  occurring  in  chronic  arthritic  cases  and  post-traumatic  lesions.  These  latter 
are,  moreover,  described  by  him  also  amongst  the  hystero-traumatisms. 

(3)  The  symptoms  are  not  completely  new. 

(4)  They  are  to  be  found  to-day  in  many  wormded  who  do  not  present  any 
organic  lesion,  but  merely  ordinary  hystero-traumatisms. 

(5)  They  do  not  constitute  any  contra-indication  to  psychotherapeutic  treat- 
ment, even  of  an  heroic  kind,  and  these  patients  are  cured  as  well  as  the  others. 
In  any  case,  from  the  fact  of  a  failure  of  cure  it  is  not  to  be  inferred  that  they  are 
not  the  subjects  of  hystero-traumatism;  for  some  succeed  where  others  have 
failed,  of  which  the  patient  whose  case  has  been  recorded  is  an  example. 

(6)  From  a  medical  and  military  point  of  view,  such  patients  (when  they  have 
not  been  attacked  with  organic  affections)  should  be  considered  and  treated 
as  cases  of  hystero-traumatism.  It  would  be  dangerous  to  make  them  out  to 
be  organically  diseased  or  to  treat  them  as  such,  for  the  contagion  of  example 
would  make  ravages  in  neurological  centres. 

(7)  To  cure  these  patients  we  must  employ  all  the  most  energetic  means  which 
the  authorities  have  placed  at  our  disposal,  from  moral  suasion  to  the  most 
painful  electiic  currents.  In  this  way  multiple  successes  are  achieved,  and  the 
army  recuperated  with  vigorous  subjects. 

Such  are  the  conclusions  to  which  Dr.  Ferrand  and  his  colleagues  have  been 
led  by  a  practice  of  eighteen  months  in  one  of  the  most  important  neurological 
centres  in  France. — T.  Drapes,  J.  ment.  sci.,  Lond.,  63:  602-0-i,  Oct.  1917. 

Landau,  Principle  of  Psychicallsolation  in  the  Treatment 

of  Functional  Nervous  Disturbances  (Le  principe  d'isolement 
psychique  dans  le  traitement  des  troubles  nerveux  fonctionnels) 
Bull.  Acad,  med.,  Paris,  77:  701-04,  May  29,  1917 

Landau  describes  a  new  mode  of  treatment  which  he  has  found  of  great 
value  in  most  cases  of  functional  nervous  troubles  in  warfare;  he  has  thus  treated 
about  fifty  cases.  The  patient  is  brought  into  the  presence  of  other  patients 
who  present  similar  symptoms,  l)ut  of  an  organic  nature.  A  detailed  clinical 
examination  of  the  patient  is  then  made  in  the  midst  of  his  fellow-patients.  If, 
for  example,  his  case  be  one  of  a  functional  causalgia,  the  physician  reviews 
briefly  the  history  of  the  case,  its  mode  of  production,  and  the  destructive  signs 
of  these  conditions.  In  the  case  of  a  functional  palsy  of  a  nerve,  the  physician 
discusses  openly  before  all  the  patients  the  electrical  changes,  and  then  makes 
an  electrical  examination  of  the  functional  case  and  of  an  organic  one.  As  a 
rule,  after  a  few  of  these  public  demonstrations  and  lectures,  and  sometimes 
from  the  first  one,  there  is  benefit  to  the  patient.  By  means  of  this  kind  of  pro- 
cedure Landau  claims  that  a  state  of  "psychical  isolation"  is  set  up.  He 
describes  it  also  as  a  sort  of  bringing  the  functional  patient  face  to  face  with 


himself.  The  application  of  the  treatment  must  to  some  extent  vary  with  the 
particular  case.  Three  cases  are  described  to  illustrate  these  points. — L.  J.  Kidd, 
Rev.  of  neurology  and  psychiatry  15:  334-35,  Aug.-Sept.  1917. 


Hoven,  Mental  Diseases  and  the  War.     Archiv.    med. 

Beiges,  Paris,  May  1917 

Hoven  states  that  he  does  not  intend  to  go  deeply  into  this  subject,  and 
contents  himself  with  a  brief  analysis  of  the  material  which  has  come  under  his 
observation  as  military  alienist  during  the  past  14  months.  Out  of  300  cases, 
28  were  examples  of  post-traumatic  psychoses  such  as  foUow^  trauma,  cerebral 
commotion  or  moral  shock.  In  11  of  the  28  there  had  been  an  actual  injury  to 
the  cranium,  while  in  12  others  shells  had  exploded  close  to  the  victims.  Of 
the  28  patients,  16  presented  evidences  of  mental  confusion,  and  8  of  melan- 
cholia. There  were  2  cases  of  dementia  praecox,  one  of  which  the  author  de- 
scribes, adding  that  in  post-traumatic  psychoses  the  possibility  of  dementia 
praecox  should  always  be  borne  in  mind. 

With  the  exception  of  24  patients  whose  insanity  dated  from  before  the  war,  the 
remainder  of  the  material  (256  cases)  includes  the  ordinary  psychoses  of  the 
alienist,  viz.,  dementia  praecox,  61  cases,  and  melancholia,  52  cases,  followed 
by  acute  confusional  insanity,  with  16  cases,  and  progressive  general  paralysis, 
with  14  cases.  Other  psychoses  occurred  only  in  scattering  figures  (manic- 
depressive,  mental  disequilibration,  alcoholic,  etc.)  However,  under  ordinary 
psychoses  are  comprised  idiocy  and  imbecility,  with  62  cases;  i.e.,  the  mental 
ailments  were  found  to  be  associated  with  subnormal  mental  development. 
This  contingent  was,  of  course,  the  result  of  hasty  selection  during  mobilization. 
The  subjects  presented  either  mental  confusion,  melancholia,  or  nervous  crises. 
Latent  mental  weakness  was  in  part  brought  out  by  alcoholic  abuse.  Those 
actually  insane  before  the  war  were  mostly  volunteers  suflFering  from  paranoia, 
paraphrenia,  epilepsy,  and  alcoholism. 

The  author  states  there  is  no  specific  war  psychosis.  The  alleged  "battle 
hypnosis"  is  no  more  than  acute  mental  confusion  with  dream  hallucination, 
occurring  especially  in  post-traumatic  psychoses.  These  patients  are  very 
wakeful,  with  an  exaltation  of  psychic  automatism  and  a  sensorial  erethism. 
Acute  mental  confusion  is  characterized  in  general  by  lacunar  amnesia,  which 
disappears  slowly,  and  persists  after  other  symptoms  have  vanished. 

Simulation  of  insanity  is  rare,  but  dementia  praecox  often  passes  at  its  onset 
for  simulation  because  the  victims  indulge  in  silly,  absurd,  affected  behavior. 
In  true  simulation  the  patient  is  always  abnormal,  a  psychopath.  In  contrast 
with  actual  simulation,  exaggeration  is  common.  Psychopathic  deserters  are  not 
uncommon,  and  much  care  is  necessary  for  the  proper  fixation  of  responsibility. 

By  what  mechanism  does  warfare  cause  insanity?  No  one  knows  now,  but 
after  the  war  is  over  it  may  be  possible  to  answer  this  question.  No  doubt  in- 
sanity is  produced  by  a  commingling  of  psychic  and  somatic  insults.  Home- 
sickness, loss  of  sleep,  fatigue,  at  once  suggest  themselves,  and  we  may  add  appre- 
hension of  danger,  shell  concussion,  etc.  Hereditary  taint  and  history  of  neu- 
ropsychic  manifestations  are  very  common;  in  fact,  predisposition  in  some  form 
is  almost  universal.  In  some  material,  alcoholism,  whether  as  effect  or  cause  of 
predisposition,  is  present  in  a  third  of  all  cases. 

The  practical  aspect  is  diagnostic  and  not  therapeutic.  But  few  of  these  men 
are  fit  for  duty,  for  they  can  seldom  react  properly  to  discipline.  They  must  be 
mustered  out,  and,  if  necessary,  interned.  The  best  modern  treatment  is  life 
in  farm  colonies,  which  results  in  more  or  less  improvement.  The  inoffensives 
are  able  to  do  useful  work  for  the  army  in  various  capacities — basket-weaving, 
shoemaking,  woodworking,  baking,  etc. — Med.  rec.  92:637,  Oct.  13,  1917. 


-    23 

Guillain,  Georges,  and  Barre,  J. -A.  Alterations  of  Pupillary  Reac- 
tions in  Shock  due  to  Bursting  of  Large  Shells,  without  External 
Wound  (Les  troubles  des  reactions  pupillaires  dans  la  commotion 
par  eclatement  de  gros  projectiles  sans  plaie  exterieure)  Bull. 
Acad,  med.,  Paris,  78: 158-59,  Aug.  28,  1917 

A  study  of  twenty-six  cases  of  recent  shell  shock;  the  possibility  of  even  a 
minimal  wound  of  the  eyeball  was  excluded.  The  pupillary  changes  comprised 
mydriasis;  inequality  of  pupils  with  or  without  unilateral  or  bilateral  loss  of 
light-reaction,  ArgyU-Robertson  pupils,  or  the  paradoxical  light-reaction.  The 
pupillary  changes  were  commonly  transitory,  lasting  from  three  to  twenty  days 
or  longer,  and  ultimately  disappeared.  In  six  of  the  cases  there  was  xantho- 
chromia of  the  cerebrospinal  fluid  with  a  slight  meningeal  reaction.  The  ques- 
tion is  raised  whether  a  xanthochromic  or  blood-stained  cerebrospinal  fluid, 
rendered  toxic  by  haemolysis,  may  not  act  on  the  root-fibres  of  the  cranial  nerves 
either  on  the  centripetal  or  the  centrifugal  limb  of  the  reflex  pupillary  arc,  or 
whether  small  basilar  clots  may  compress  the  root-fibres.  The  central  origin  of 
these  pupillary  changes  by  small  intra-peduncular  haemorrhages  is  held  to  be 
unlikely.  The  writers  incline  to  the  belief  that  most  of  these  cases  are  of  peri- 
pheral origin,  either  a  true  commotion  of  the  retina  or  of  the  nerves  of  the  intrin- 
sic eye-muscles,  resulting  in  a  temporary  asthenia  of  one  or  both  of  these  muscles. 
— L.  J.  Kidd,  Rev.  of  neurology  and  psychiatry  15:  332,  Aug.-Sept.  1917. 

Roussy,  Gustave,  Boisseau,  J.,  and  d'Oelsnitz,  M.  Psycho-neurotic 
Contracture  of  Foot  or  Hand  (Les  acro-contractures  et  les  acro- 
paralysies)     Annales  de  med.,  Paris,  5:  515-44,  Sept.-Oct.  1917 

This  profusely  illustrated  article  reviews  the  experiences  with  141  cases  of 
contracture  or  paralysis  after  minor  woimds  of  the  region. — J.  A.  M.  A.  70:  890, 
March  23,  1918. 

Crinon,  Advanced   Psychiatric   Centers.    Progres   med., 

Paris,  33:364-65,  Oct.  27,  1917 

Psychic  changes  should  be  recorded  as  scrupulously  as  the  organic,  writes 
Crinon.  It  is  now  officially  ordered  that  the  concussion  syndrome  has  to  be 
specified  on  the  card.  The  "psychically  disabled"  should  have  their  record 
as  complete  from  the  first  as  is  the  rule  for  the  physically  maimed.  This  would 
permit  also  suitable  measures  from  the  very  first,  when  they  are  much  more 
likely  to  prove  effectual.  The  influence  on  the  brain  of  physiologic  disturbances 
from  shell-shock  or  toxic  infections  should  be  arrested  as  early  as  possible.  To 
neglect  this  allows  the  psychic  changes  to  deepen  and  crj'^stallize  into  delirium 
or  confusional  states.  All  this  requires  advanced  psychiatric  stations.  Their 
existence  is  still  further  justified  by  the  important  task  of  sifting  out  the  men  to 
be  sent  to  the  nerve  centers  and  the  psychiatry  centers  farther  back  from  the 
front.  Many  men  only  lightly  affected  could  do  well  in  them  and  be  promptly 
restored  to  full  duty.  Sent  back  into  the  interior,  their  psychic  disturbances 
become  more  and  more  confirmed  and  durable.  At  the  best,  the  men  are  returned 
after  months  of  convalescence  when,  if  they  had  been  given  specialist  treatment 
close  to  the  front,  they  would  have  been  in  the  ranks  again  in  much  less  than  a 
month.  Toxic  delirium  of  alcoholic  origin  is  often  mistaken  for  a  more  per- 
manent trouble.  It  requires  only  a  special  course  of  internment  and  treatment 
.  which  is  as  available  in  a  well-equipped  advanced  psychiatric  station  as  elsewhere. 
Men  subject  to  convulsions  can  also  be  kept  under  observation  here,  and  the 
nature  and  number  of  their  attacks  determined.  Crinon  thinks  it  is  as  absurd 
to  exempt  men  from  service  on  account  of  a  single  epileptic  seizure — which  is 
now  the  regulation — as  to  exempt  those  who  have  not  good  teeth. — J.  nerv.  and 
ment.  dis.  47:147,  Feb.  1918. 


24 

Damaye,  Henri.     Psychiatry  in  the  Army.     Progres  med.,  Paris,  33 : 
362-64,  Oct.  27,  1917 

Damaye  analyzes  638  cases  of  mental  or  nervous  aflfections  that  passed 
through  his  service  last  year.  The  mental  disturbances  were  usually  transient 
when  the  men  were  kept  back  from  the  front.  The  proportion  of  the  per- 
sisting and  incurable  cases  is  surprisingly  small  in  comparison  to  the  more 
or  less  prompt  recovery  of  the  others.  The  mixed  cases  are  especially  numer- 
ous, namely,  those  in  an  intermediate  stage  between  mental  debility  and  de- 
mentia prsecox,  with  and  without  delirium,  or  between  hebephrenia  and  actual 
loss  of  mental  balance.  Hysteroepilepsy  and  hysteroneurasthenia  were  par- 
ticularly frequent.  The  various  types  of  mental  anomalies  are  listed;  the  largest 
group  was  71  cases  of  melancholia  with  notions  of  persecution;  39  cases  of 
melancholia  with  a  neurastheniform  state;  51  of  acute  brief  attacks  of  delir- 
ious excitement  with  hallucinations,  and  37  of  simple  mental  debility.  In 
24  cases  there  was  desire  to  commit  suicide;  in  19  malaria  was  commencing, 
and  in  399  there  was  sUght  albuminuria,  with  more  or  less  perfect  compensation 
of  some  heart  defect.  The  albuminuria  disappeared  in  most  of  them  after  a 
week  of  rest,  but  in  others  it  persisted  unmodified.  The  etiology  of  these  nervous 
and  mental  disturbances  is  complex,  predisposition,  emotions,  intoxications  and 
fatigue  all  cooperating.  The  attacks  of  convulsions  nearly  always  coincided 
with  exhausting  fatigue.  Syphilis  is  a  predisposing  factor  in  the  mental  dis- 
turbances, and  a  combination  of  malaria  and  alcoholism,  but  all  the  mental  and 
neuropathic  troubles  and  even  the  syndrome  of  general  paralysis  can  be  started 
by  some  concussion  mishap.  This  "presses  the  button"  as  it  were.  Treatment 
in  all  cases  was  to  give  at  once  a  bath  at  37°  C.  for  one  half  hour  if  the  man  is 
tranquil,  and  for  an  hour  at  40°  C.  if  he  is  excited.  A  calomel  purge  was  then 
given  and  the  man  was  put  to  bed.  The  baths  are  repeated  daUy  and  no  food 
but  milk  is  allowed  for  two  or  three  days.  If  the  lu-ine  findings  are  negative,  he 
is  then  given  the  restricted  and  then  the  full  milk-vegetable  diet.  By  this  means 
the  effects  of  the  digestive  disturbances,  etc.,  are  overcome.  No  wine  is  ever 
allowed;  milk  or  "glyzin"  are  the  only  beverages  given.  The  patients  are  aU 
given,  besides,  a  solution  of  40  drops  of  tincture  of  iodin  in  100  gm.  gum  mixture, 
fractioned,  during  the  day.  This  is  kept  up  for  five  to  ten  days.  It  serves  to 
sterilize  the  digestive  tract,  promote  leukocytosis,  and  acts  as  a  general  tonic. 
Cold  baths  are  not  advisable,  but,  if  conditions  call  for  it,  a  daily  injection  of  5 
eg.  of  sodium  cacodylate  is  given.  When  there  is  much  mental  distress,  morphin 
is  the  resource  and  the  much  excited  patients  are  given,  beside  the  baths,  4  gm. 
of  chloral  in  120  gm.  of  gum  mixture  at  night  and  possibly  a  very  cautious  in- 
jection of  hyoscin  hydrobromate.  The  most  practical  arrangement  for  the 
psychiatric  service  is  to  have  an  advanced  station,  moving  with  the  front  lines, 
and,  farther  back  where  aU  is  quiet,  a  psychiatric  center  and  a  neurologic  center 
to  which  the  men  can  be  evacuated  from  the  advanced  station.  The  evacuation 
should  always  be  in  charge  of  specialist  attendants. — J.  nerv.  and  ment.  dis.  47: 
150-51,  Feb.  1918. 

Cheyrou,  Asthenia  from  Overexertion  at  the  Front.    Pro- 

gres med.,  Paris,  32:  378,  Nov.  10,  1917 

The  regimental  physician  often  encounters  pathologic  conditions  for  which 
fatigue  is  the  main  factor.  Cheyrou  has  found  that  this  was  the  clue  to  many 
clinical  pictures,  and  that  improvement  promptly  followed  treatment  addressed 
to  the  fatigue.  Lumbago  is  the  simplest  and  earliest  form,  and  the  horizontal 
position  for  twenty -four  hours  banishes  it  as  a  rule.  Fatigue  fever  is  not  un- 
common, after  special  and  prolonged  exertion,  with  constipation,  pains  back  of 
the  eyes  and  in  the  back  and  along  the  tibias,  with  acceleration  of  the  pulse  and 


25 

rise  of  temperature.  All  of  this  may  disappear  under  a  few  days  of  bed  rest, 
repeated  laxatives  and  restriction  to  water,  with  administration  of  quinin.  In 
the  severer  cases  the  digestive  apparatus,  kidneys  or  heart  may  bear  the  brunt  of 
the  attack.  Some  of  the  men  returning  from  the  trenches  at  Verdun  had  reached 
such  a  stage  of  autointoxication  from  the  prolonged  constipation  that  enteritis 
followed  and  several  weeks  elapsed  before  normal  conditions  were  restored.  The 
nervous  system  shows  the  effect  of  excessive  fatigue  in  various  ways  that  he 
describes.  These  asthenic  states,  scarcely  knouTi  before  the  war,  are  prevalent, 
and  reduce  the  resisting  power  to  infections.  Prophylaxis  should  include 
measures  to  keep  the  diet  varied  and  oppose  constipation.  Suitable  provisions 
for  sleeping  would  aid  much  in  proper  recuperation.  Overexertion  might  be 
avoided  by  better  distribution  of  energy  and  labor.  The  watches  should  be 
relieved  of  tener,  and  supplementary  rations  and  hot  drinks  supplied  in  the  hardest 
sectors.  As  fatigue  reduces  the  alkalinity  of  the  blood,  alkalies  should  be  sup- 
plied artificially,  and  diuretics  and  laxatives  given  to  keep  the  emunctories  open. 
Cheyrou  suggests  in  treatment  progressively  large  injections  of  strychnin  to 
reenforce  the  nervous  system,  giving  drops  of  epinephrin  to  restore  muscular  tone. 
He  advises  fiu-ther  utilization  of  physiologic  serum  with  epineplirin.  Administra- 
tion of  extracts  of  the  suprarenal  capsules  has  aided  materially  in  overcoming 
asthenia  and  hastening  elimination  of  toxins.  Extract  of  testicles  might  be 
given  with  it,  concluding  with  a  course  of  tonics  and  means  to  recalcify  the  or- 
ganism.—J.  A.  M.  A.  70:  350,  Feb.  2,  1918. 

Guillain,  Georges,  and  Barre,  J.-A.  Transient  Sphincter  Disturbance 
from  Shell  Shcck.  Bull.  Soc.  med.  des  Hop.,  Paris,  41:1110, 
Nov.  16,  1917 

Guillain  and  Barre  report  twelve  cases  of  complete  retention  of  urine  or  in- 
continence of  urine  after  shell  concussion  without  direct  contact.  Such  sphincter 
disturbances  are  rare  as  they  have  encountered  only  these  twelve  cases  among 
several  hundred  men  with  shell  shock.— J.  A.M.  A.  70:  815,  March  16,  1918. 

Crouzon,  O.,  and  Mauger,  N.  Frequency  of  Infectious  Antecedents  in 
War  Tachycardias.  Bull.  Soc.  med.  des  Hop.,  Paris,  41 :  1237, 
Dec.  7,  1917 

Crouzon  and  Mauger  state  that  in  ninety-six  cases  of  tachycardia  in  soldiers 
on  active  service  they  found  over  50  per  cent  with  a  history  of  typhoid,  acute 
articular  rheumatism  or  other  infectious  disease,  nearly  all  before  the  war.  In 
four  other  cases  the  tachycardia  developed  after  gassing;  in  four  after  concussion, 
and  in  two  after  a  wound  of  the  chest.  Dumas,  in  the  discussion  that  followed, 
remarked  that  he  had  sometimes  found  tachycardia  an  early  symptom  of  pul- 
monary tuberculosis.  He  added  that  some  of  the  candidates  for  the  aviation 
course  came  from  the  front  with  tachycardia,  but  it  subsided  under  rest  and 
restriction  of  tobacco  and  alcohol.  The  men  were  anxious  to  get  to  flying  and 
they  usually  threw  off  the  tachycardia.  The  power  of  psychic  influence  is  well 
shown,  Josue  added,  by  the  tachycardia  that  develops  in  men  being  examined 
for  the  aviation  course;  it  develops  solely,  he  declares,  from  the  candidates'  fear 
of  being  rejected.— J.  A.  M.  A.  70: 1040^  April  G,  1918. 

Boisseau,  J.,  and  D'Oelsnitz,  M.  Hysteria  as  an  Element  in  Con- 
tracture of  the  Hands  (Mains  figees)  Paris  med.  7:  501,  Dec. 
22,  1917 

Boisseau  and  D'Oelsnitz  refer  to  cases  of  contracture  or  paralysis  in  soldiers 
with  or  witliout  organic  lesions.  They  have  had  108  cases  of  the  kind  in  which 
the  contracture  had  lasted  from  one  to  eighteen  months  in  G3  and  from  eighteen 


26 

to  thirty-six  months  in  45.  The  contracture  was  of  the  "accoucheur's  hand"  or 
the  "priest  blessing"  type  in  many,  and  was  usually  of  a  type  that  can  be  repro- 
duced at  will.  These  and  other  features  of  the  cases  convinced  them  that  the 
motor  element  in  the  affection  was  of  hysteric  or — as  they  prefer  to  call  it — of 
pithiatic  origin  and  hence  susceptible  of  being  cured  by  psychotherapy.  They 
prepared  the  men  for  the  treatment  by  keeping  them  in  a  circle  of  already  cured 
cases,  thus  impressing  on  them  the  possibility  of  a  cure.  Then  the  application 
of  systematic  psychotherapy  resulted  in  a  sudden  and  complete  cure  of  the  motor 
element  in  71  cases;  in  17  cases  the  cure  was  rapid  and  complete,  while  it  took 
some  time  for  the  complete  cure  in  14  cases.  The  psychotherapy  failed  com- 
pletely in  only  6  cases,  and  in  all  these  there  was  no  concomitant  organic  lesion. 
Of  course  the  long  disuse  of  the  muscles  took  longer  before  normal  conditions 
were  restored  but  the  abrupt  overcoming  of  the  long  contracture  confirmed  the 
pithiatic  nature  of  the  contracture  or  paralysis. — J.  A.  M.  A.  70 :  576-77,  Feb.  23, 
1918. 

Babinski,  J.,  and  Froment,  J.  Hysteria,  Pithiatism  and  Functional 
Nervous  Disturbances  of  War  (Hysteric,  pithiatisme  et  troubles 
nerveux  d'ordre  reflexe  en  neurologie  de  guerre)  Paris,  Masson, 
1918.    295  p. 

In  a  previous  issue  of  the  first  edition  of  this  work  by  Babinski,  we  have  had 
cause  to  say  that  Babinski's  contributions  offer  little  or  nothing  to  the  interest  of 
the  hysterical  problem  by  his  erection  of  a  new  entity,  which  he  terms  pithiatism, 
namely,  a  disease  which  is  caused  by  suggestion  and  can  be  cured  by  persuasion. 
The  modern  student  of  medical  phenomena  finds  nothing  dynamic  in  such  a 
discussion  and  no  student  of  energetics  who  has  completed  the  study  of  the 
activities  of  the  human  body  can  obtain  from  this  book  any  fundamental  phil- 
osophical concepts  of  any  value.  On  the  other  hand  the  clinician  will  find  any 
number  of  extremely  interesting  descriptive  points  well  illustrated  and  admirably 
outlined.  To  the  student  of  the  deeper  psychology,  independent  of  the  par- 
ticular phase  in  which  it  may  be  presented,  Babinski's  conception  is  superficial 
and  static— N.  Y.  med.  j.  107:  384,  Feb.  23,  1918. 


GERMAN  LITERATURE 

Periodicals  Abstil-^-cted 
Deutsche  medizinisehe  Wochenschrift,  Berlin 
Jahreskurse  fiir  artzliche  Fortbildung,  Munich 
Medizinisehe  Klinik,  Berlin 

Monatsschrift  fUr  Psychiatric  und  Neurologic,  Berlin 
Miinchener  Medizinisehe  Wochensclu-ift 
Neurologische  Centralblatt,  Leipzig 

Psychologische  und  Neurologische  Wochenschrift,  Hamburg 
Sammlung  Zwangloser  Abhandlunger  zur  Neuro-  und  Psycho- 
pathologic  des  Kindesalters,  Jena 
Schmidts  Jahrbuch,  Bonn 


GERMAN   LITERATURE 

Buschau,   George.    War  Psychosis  (tJber  Kriegs-Psychosen)  Med. 
Klin.,  Berlin,  lo:  1588-91,  Oct.  18,  1914 

It  is  a  well-known  fact  that  accidents  cause  psychic  disturbances  more  violent 
both  in  intensity  and  duration  than  the  results  of  physical  injuries.  The  clinical 
picture  resulting  from  the  fright  and  the  shock  connected  with  these  accidents 
is  known  as  "fright  neurosis"  or  traumatic  neurosis.  An  ordinary  shock  is  often 
strong  enough  to  affect  seriously  the  nervous  system.  The  patient  becomes 
pale,  his  eyes  protrude,  his  mouth  opens,  speech  is  lost,  his  hair  stands  on  end, 
perspiration  is  profuse,  the  heart  begins  to  palpitate,  hands  and  legs  tremble  and 
he  loses  control  over  bladder  and  rectum.  In  severe  cases,  the  patient  becomes 
confused  and  excited,  talks  incoherently,  etc.  These  conditions  generally  clear 
up  in  a  short  time,  but  sometimes  they  develop  into  chronic  psychic  disturbances. 
If  nerve  shock  is  complicated  by  permanent  sequelae,  we  must  assume  a  predis- 
position of  the  nervous  system,  either  congenital  or  acquired.  In  other  words, 
the  individuals  so  affected  are  either  psychopaths  or  are  predisposed  to  a  nerv- 
ous or  mental  disease  through  the  influence  of  alcohol,  tobacco,  poisonous  gases, 
syphilis  or  other  infectious  diseases,  and  so  are  not  able  to  resist  the  psychic 
strain. 

War,  with  its  terrors  and  emotional  shocks,  is  a  more  potent  factor  than  any 
other  in  the  causation  of  mental  disease.  Here  the  writer  reports  in  brief  ob- 
servations made  during  previous  wars. 

The  causal  factors  of  mental  disease  may  be  either  physical  or  psychic,  as,  for 
instance,  injuries  about  the  head,  excessive  heat,  intemperate  use  of  alcohol, 
contagious  diseases  accompanied  by  fever,  physical  exertions  of  every  kind, 
forced  marches,  lack  of  sleep  and  insufficient  food,  worry  about  family  affairs, 
great  emotional  tension  before  battle,  horrifying  impressions  during  battle,  panic 
during  retreat,  etc. 

The  observations  made  by  Nasse  in  1866  and  those  of  Jolly  are  compared.  A 
synopsis  of  the  official  report  of  the  Sanitary  Commission  at  the  end  of  the 
Franco-Prussian  War  in  1871,  which  contains  a  detailed  symptomatological  study 
of  the  forms  of  mental  diseases  found  at  that  time,  is  then  given. 

The  writer  differentiates  between  cases  of  mental  disease  which  originate  with 
head  injuries  and  are  caused  by  cerebral  concussion  or  by  organic  lesion  of  the 
brain,  and  those  which  are  of  a  purely  functional  nature. 

Dr.  Otto  Holbeck,  the  Russian  psychiatrist,  is  quoted  by  the  writer.  Holbeck 
believes  that  loss  of  consciousness  immediately  after  bullet  shot  through  the 
head  does  not  occur  frequently,  and  then  only  in  comparatively  severe  injuries. 
After  regaining  consciousness,  the  patient  shows  several  forms  of  psychic  dis- 
turbance such  as  dullness,  apathy,  depression,  impaired  memory,  especially  re- 
trograde amnesia,  childish  manner,  abnormal  sensibility,  increased  irritability, 
fits,  rage,  violence,  delirium,  etc.,  and  sometimes  great  hilarity,  mental  confusion, 
hypochondriac  and  melancholic  states  and  intense  emotionalism.  These  con- 
ditions are  caused  by  concussion  of  the  brain,  which  is  diffused  mechanical 
injury,  and  not  by  the  organic  change  of  a  particular  part  of  the  biain. 

The  writer  makes  the  following  statements  with  regard  to  the  prevalence  of 
psychic  disturbances  that  are  of  a  purely  functional  nature: 

Dementia  precox  leads  with  35%;  psychopathic  constitution  follows  with 
^5.5%;  then  come  epileptic  insanity,  alcoholism,  melancholia  and  depressive 
conditions,  delirium,  neurasthenia,  hysteria  and  progressive  paralysis.  All  of 
these  disturbances  are  found  in  times  of  peace  as  well  as  under  war  conditions. 

29 


30 

The  most  frequent  disturbance  among  soldiers  is  a  peculiar  clinical  picture  which 
the  writer  wishes  considered  as  war  psychosis  far  excellence.  It  resembles  cere- 
bral neurasthenia  to  a  great  extent,  but  includes  also  hysterical  symptoms  and 
conditions  of  mental  dullness.  This  symptom  complex  is  identical  with  "de- 
fatigatio"  known,  since  1870,  as  exhaustion  psychosis  plus  terror  psychosis. 
The  symptoms  chronologically  arranged  are  great  depression,  marked  nerv- 
ous exhaustion  and  increased  debility  of  the  nervous  system,  with  a  favorable 
prognosis. 

The  writer  briefly  reviews  the  observations  of  Awtokratow,  then  those  of 
Krauser  made  during  the  East  Asiatic  expedition.  The  clinical  pictures  were 
various  but  coincided  to  a  great  extent  with  those  described  by  Stierlin  as  psy- 
chical consequences  of  catastrophes  such  as  the  earthquake  of  Valparaiso,  the 
railroad  accident  of  Muellheim,  etc. 

The  author  believes  that  exhaustion  and  horror  are  to  be  considered  the  main 
etiological  factors  of  war  psychoses.  The  fact  that  not  all  individuals  exposed  to 
these  conditions  are  affected  shows,  moreover,  that  predisposition  must  also  be 
considered  as  an  important  etiological  factor.  An  inferior  psychopathic  consti- 
tution shows  itself  in  a  lowered  resistence  to  violent  external  impressions. 

The  extensive  statistics  of  Awtokratow  concerning  the  frequency  of  psychoses 
during  the  Russo-Japanese  War  are  of  little  value  because  the  abuse  of  alcohol 
in  the  Russian  army  gives  a  false  impression.  According  to  these  statistics, 
alcohol  psychoses  amounted  to  34.68%  among  the  officers  and  10.86%  among 
the  enlisted  men.  Epilepsy  among  oflBcers  was  4.88%,  among  enlisted  men, 
27.9%. 

Weyert,  Psychiatric  Observations  and  Experiences  in  the 

Army  (Militar-Psychiatrische  Beobachtungen  und  Erfahrungen) 
Samml.  zwangl.  Abhandl.  ii:  2-150,  1914-15 

The  mihtary  authorities  are  attempting  to  lessen  the  number  of  war  neuroses 
and  psychoses,  especially  borderline  cases,  by  preventing  the  enlistment  of  the 
mentally  diseased  and  by  recognizing  as  early  as  possible  all  those  in  the  army 
unfit  for  military  service.  To  further  this  endeavor,  it  should  be  compulsory  for 
the  insane  asylums,  sanitoria,  institutions  for  the  feebleminded,  and  the  like,  to 
report  all  such  cases  to  the  military  authorities.  In  spite  of  these  precaiitions 
many  inferior  men  are  admitted  to  the  army.  It  should  therefore  be  the  duty  of 
oflBcers  to  report  immediately  all  cases  that  attract  attention  because  of  peculiar 
behavior,  stupidity  or  dullness.  Pamphlets  and  lectures  on  popular  psychiatry 
would  always  help  the  officers  to  realize  that  men  with  such  symptoms  are  not 
always  malingerers  and  that  such  cases  require  immediate  medical  treatment. 
To  further  this  purpose,  special  military  psychiatric  bases  have  been  established. 

At  Posen,  106  cases  were  studied  and  the  following  diagnoses  made: 


31 


Total 
number 

Enlisted 
men 

Non-com- 
missioned 
officers 

Commis- 
sioned of- 
ficers 

Alcoholic  psychoses 

Dementia  praecox 

Progressive  paralysis 

Organic  brain  diseases 

Manic-depressive  psychoses .  .  . 
Chronic  paranoia 

9 

23 

1 

4 

2 

1 

11 

5 

4 

20 

25 

1 

106 

4 

20 

0 

1 

0 

1 

11 

0 

3 

20 

22 

1 

83 

4 
3 
1 
2 
1 
0 
0 
4 
0 
0 
1 
0 

16 

1 
0 
0 
1 
1 
0 

Epilepsv 

0 

Neurotic  constitution 

Neurasthenia 

Mental  defect 

1 
1 

0 

Psychopathic  constitution  .... 
Hallucinatory  psychoses 

Total 

2 
0 

7 

These  stations  were  intended  to  be  used  for  purely  mental  cases,  therefore 
neurasthenia  and  hysteria  are  represented  by  low  figures.  It  is  evident  that  the 
presence  of  mental  disease  has  an  unfavorable  influence  upon  purely  nervous 
cases,  therefore  separate  services  are  advisable. 

Statistics  show  that  a  large  percentage  of  mental  cases  occur  among  volun- 
teers. Many  of  them  deny  their  defects  in  order  to  enlist,  especially  when  they 
have  been  unsuccessful  elsewhere.  They  frequently  show  a  tendency  to  moral 
laxness.  Stier  states  that  in  France  eighty  per  cent  of  the  deserters  were  from 
the  volunteers. 

The  prognosis  for  types  of  dementia  precox  in  the  war  is  much  more  favor- 
able than  in  times  of  peace.  There  were  no  very  severe  cases.  Investigation 
showed  that  in  about  fifty  per  cent  of  the  cases  hereditary  factors  could  be  dem- 
onstrated. It  was  proved  also  that  in  about  fifty  per  cent  symptoms  such  as  a 
great  desire  to  work  followed  by  periods  of  laziness,  boastfulness,  irritability, 
sensitiveness,  anxiety,  vanity,  egotism,  emotionalism,  shyness,  a  tendency  to 
seclusion,  neglect  of  personal  appearance,  megalomania,  attacks  of  vertigo, 
hallucinations,  headaches,  etc.,  had  existed  before  enlistment.  In  such  cases, 
the  existence  of  dementia  precox  before  enlistment  was  assumed  and  claims  for 
indemnity  were  not  granted.  Simon  believes  that  predisposition  should  be  con- 
sidered only  as  a  secondary  etiological  factor  and  that  the  difficulties  and  hard- 
ships of  military  service  should  be  considered  the  chief  cause.  Most  of  the  other 
writers  on  this  subject,  including  the  writer  of  this  article,  are  of  the  opposite 
opinion.  Very  often,  after  a  several  months'  stay  in  the  army,  patients  will  be 
discharged  who  had  shown  symptoms  of  schizophrenia  previous  to  their  entering 
the  service,  but  who  were  apparently  normal  during  those  few  months.  In  such 
cases,  the  examining  physician  is  not  to  be  held  responsible  for  overlooking  the 
symptoms.  The  possibility  of  occurrence  is,  therefore,  an  important  point 
in  deciding  forensic  questions.  Of  the  cases  sent  by  the  military  courts  to  the 
stations  for  examination  as  to  their  degree  of  responsibility  in  committing  of- 
fences, twelve  were  diagnosed  as  hebephrenics,  eight  as  catatonics  and  one  as  a 
paranoiac. 

It  is  difficult  to  differentiate  clearly  between  mental  dullness  as  a  physiological 
phenomenon  and  congenital  mental  weakness  as  a  psychopathological  phenomc- 


32 

non.  This  is  especially  true  in  individuals  who  have  received  no  intellectual  or 
moral  training,  for  then  it  is  difficult  to  know  whether  the  defect  is  due  to  the 
lack  of  training  or  to  a  pathological  condition.  A  diagnosis  of  congenital  mental 
debility  can  be  pronounced  only  when  it  is  clear  that  attempts  at  establishing 
proper  standards  of  conduct  tln"ough  education  have  proved  futile.  Such  dem- 
onstration is  difficult  on  account  of  the  lack  of  authoritative  information  to  be 
had  from  witnesses  such  as  ministers,  teachers,  parents,  etc.  Hereditary  factors 
could  be  proven  in  twelve  of  the  twenty  cases  diagnosed  as  congenital  mental 
debility,  parental  tuberculosis  among  them.  Some  of  the  symptoms  in  men  of  a 
retiring  disposition  were  abnormal  voraciousness,  lack  of  personal  cleanhness 
and  of  a  sense  of  order,  incapability  to  divide  a  given  period  of  time  properly 
so  as  to  perform  necessary  duties,  inability  to  follow  instructions,  stupidity,  poor 
memory,  absent-mindedness,  and  insubordination.  In  cases  of  the  erethical 
type,  these  and  other  symptoms  were  present,  such  as  boastf ulness,  excitability, 
a  tendency  to  joke,  etc.  The  writer  groups  cases  of  congenital  mental  debihty 
into  three  classes  as  follows: 

1.  Cases  of  a  mild  type,  that  may  still  be  used  for  military  service. 

2.  Cases  of  moderate  severity,  where  military  service  is  out  of  the  question 
but  where  the  individual  is  responsible  for  his  actions. 

3.  Severe  cases,  which  exclude  both  the  possibility  of  military  service  and  re- 
sponsibility for  actions. 

Many  views  have  been  expressed  as  to  the  nature  of  epilepsy.  In  this  con- 
nection the  question  is  simply  whether  or  not  genuine  chronic  epilepsy  may  be 
caused  by  skull  injuries.  Binswanger,  Mendel  and  others  admit  the  possibility. 
Surgeons  and  neurologists  with  surgical  knowledge  recognize  a  traumatic  gen- 
uine epilepsy,  and  believe  that,  where  the  clinical  diagnosis  fails  to  recognize  a 
traumatic  etiology,  an  operation  may  reveal  convincing  signs.  X-rays  may  also 
help  in  establishing  the  diagnosis  of  traumatic  epilepsy. 

The  writer  agrees  with  Redlich,  that  in  trying  to  establish  an  epileptic  dia- 
thesis, only  those  cases  should  be  considered  epileptics  that  give  proof  of  true 
epileptic  fits.     So-called  psychic  equivalents  should  be  regarded  with  skepticism. 

Cases  of  general  psychopathic  constitution  were  frequent.  The  main  etio- 
logical factor  in  fifty  per  cent  of  these  cases  was  heredity.  Those  that  exhibited 
congenital  causes  were  (1)  cases  of  hereditary  degenerative  constitution  of  the 
general  type,  (2)  cases  of  an  epileptoid  nature,  (3)  cases  of  unstable  temper- 
ament, (4)  cases  of  sexual  perversion,  (5)  degenerates  with  constitutional  states 
of  depression.  Traumatism  is  considered  an  etiological  factor  in  acquired  psy- 
chopathic constitutions.     Cases  of  each  type  are  described  in  detail. 

Chronic  paranoia  was  of  rare  occurrence,  comprising  less  than  one  per  cent  of 
all  the  admissions.  The  age  of  the  men  varied  from  twenty  to  forty  years. 
This  group  consisted  of  chronically  querulous  individuals  always  engaged  in  a 
fight  for  their  rights,  with  or  without  cause. 

Neurotic  constitution  and  acquired  neurasthenia  were  very  rare,  and  only  a 
few  cases  of  hysteria  came  under  observation.  Among  the  organic  brain  diseases 
were  cerebral  lues,  progressive  paralysis  and  cerebral  tumor.  The  writer  gives 
his  experiences  with  cases  that  had  previously  been  inmates  of  a  reformatory, 
which  group  comprised  14.4%  of  the  cases  observed.  Numerous  statistical 
tables  are  given. 

Mendel,  Kurt.  Psychiatric  and  Neurological  Observations  at  the 
Front  (Psychiatrisches  und  Neurologisches  aus  dem  Felde) 
Neurol.  Centralbl.,  Leipsic,  34:  2-7,  Jan.  2,  1915 

The  writer  has  found  that  the  occurrence  of  psychoses  in  the  present  war  is 
astonishingly  rare.     This  is  probably  due  to  the  thoroughness  of  the  examinations 


33 

at  the  time  of  conscription  which  eliminate  all  the  psychologically  doubtful 
cases. 

Special  divisions  for  mental  diseases  in  the  field  hospitals  were  unnecessary. 
Isolation  in  a  special  room  or  in  barracks  in  the  grounds  of  the  hospital  was  suf- 
ficient until  the  patients  could  be  transported  to  the  base  hospital.  During  the 
process  of  transportation  they  had  to  be  kept  very  quiet.  This  was  accomplished 
by  a  subcutaneous  injection  of  morphine  and  hyoscin,  and  in  one  case  by  mechan- 
ical restraint.  The  latter  procedure  will  often  be  necessary  on  account  of  the 
lack  of  continuous  baths  or  trained  attendants. 

War  psychoses  as  a  nosological  entity  do  not  exist,  but  war  may  give  to  psy- 
choses a  distinctive  coloring.  For  example,  patients  in  the  operating  room  under 
narcosis  talked  only  about  war  and  military  service,  giving  commands,  making 
reports,  etc.,  during  the  period  of  excitement.  Even  in  other  conditions  such 
as  hallucinations,  etc.,  war  was  always  in  the  foreground.  In  one  case  of  amentia, 
however,  the  patient  did  not  know  where  he  was  and  imagined  himself  to  be  in  an 
insane  asylum. 

The  writer  confirms  Bonhoffer's  statement  with  regard  to  dementia  precox 
that,  considering  the  age  of  the  majority  of  soldiers,  he  believes  the  war  will  cause 
a  great  number  of  cases  of  schizoplirenia. 

He  has  not  observed  any  cases  of  manic-depressive  psychoses.  Hysteria  was 
usually  more  frequent  among  officers  than  among  privates.  The  majority  of 
patients  accused  of  disciplinary  offenses  were  chronic  alcoholics. 

The  same  article  also  treats  of  the  writer's  experiences  with  cases  of  tetanus. 

Jolly,  P.  Observations  in  the  Nervous  Division  of  a  Reserve  Hospital 
(Erfahrungen  auf  der  Nervenstation  eines  Reserve  Lazaretts) 
Schmidts  Jahrb.,  Bonn,  82:  141-47,  March  1915 

The  paper  is  based  upon  319  cases  observed  by  the  writer  in  the  reserve  hospital 
at  Nuremberg.  They  were  men  between  the  ages  of  eighteen  and  forty-five 
who  had  been  found  fit  for  service,  trained  for  a  brief  time,  and  had  then  served 
at  the  front  for  a  shorter  or  longer  period.  There  w-ere  no  cases  of  pure  psychosis, 
for  these  were  treated  in  a  special  psychiatric  ward,  but  cases  of  degeneracy  and 
psychopathic  constitution  were  observed.  Patients  of  the  former  type  usuallj' 
combined  some  form  of  malingering  with  minor  ailments.  It  was  difficult  to 
classify  the  psychopathic  cases  as  many  of  them  were  of  the  border-line  type. 
If  such  men  reach  the  front,  they  are  likely  to  cause  much  trouble,  both  for  them- 
selves and  their  comrades,  and  arc  especially  susceptible  to  alclioholic  temptation 
and  stimulation.  It  is  interesting  to  note  that  not  a  single  case  capable  of  being 
diagnosed  as  general  physical  and  nervous  debility  was  found  among  army  re- 
cruits.    All  men  of  this  type  had  been  weeded  out  during  the  reservist  stage. 

Among  tlie  patients  eighty  were  diagnosed  as  neurasthenic.  Cases  of  cardiac 
neurosis  were  included  in  this  group.  Most  of  these  patients  liad  manifested 
symptoms  of  nervous  trouble  before  the  war.  Those  who  claimed  to  have  been 
perfectly  healthy  before  entering  the  service  generally  exhibited  tlio  clinical 
picture  of  exhaustion  neurasthenia.  Characteristic  symptoms,  observed  mostly 
in  officers,  were  a  tendency  to  weep  and  great  irritability. 

The  diagnosis  of  fifty  cases  was  hysteria.  Spasmodic  fits  appeared  as  the 
predominant  symptom.  Some  patients  had  shown  evidence  of  these  previous  to 
service;  in  others  Ihey  developed  after  enlistment.  The  fits  varied  from  slight 
twitchings  during  perfectly  conscious  states  to  the  most  violent  convulsions  at- 
tended by  unconsciousness.  In  one  patient  they  assumed  a  most  dramatic  form. 
The  man  would  first  be  overc;ome  by  a  violent  attiwk  of  treniblhig,  after  which  he 
would  rehearse  silently  some  liattle  scene,  going  through  the  motions  of  loading 
his  rifle,  aiming,  firing,  etc.,  followed  by  a  second  trembling  fit;  then  he  would 
become  calm  and  sink  into  a  period  of  total  amnesia.     Tiiese  patients  are  gener- 


34 

ally  irritable  and  averse  to  discipline,  but  after  cure  many  of  them  can  be  returned 

to  the  front. 

The  chief  etiological  factors  are  physical  and  mental  over-exertion,  shell  shock, 
and  heat  stroke.  The  condition  in  one  case  had  been  caused  by  the  man's 
having  to  spend  the  night  near  a  pile  of  dead  horses. 

A  number  of  interesting  cases  of  hysterical  paralysis  are  described.  In  one, 
in  which  the  man  lost  the  entire  use  of  both  arms  after  slight  shell  shock,  it  was 
found  that  the  patient,  ten  years  previous,  had  had  a  stroke  of  radial  paralysis. 
His  condition  of  shell  shock  showed  improvement  upon  application  of  the  f  aradic 
current.  The  writer  believes  that  in  cases  of  general  asthenia  the  desire  for  war 
indemnity  plays  an  important  part.  Symptomatology  of  several  cases  is  given  in 
detail. 

Another  group  of  the  hysterical  type  is  comprised  of  cases  of  psychogenic 
tremor  and  similar  motor  disturbances.  Causative  factors  are  shell  shock, 
exhaustion  and  climatic  conditions.  Treatment  through  mental  suggestion  by 
assuring  the  patient  that  his  troubles  are  curable  and  non-organic  in  nature 
seemed  the  most  generally  successful  thereapeutic  method.  Other  forms  of  treat- 
ment used  were  bromides,  opiimi,  wet  packs,  baths,  massage  and  faradization. 
Sometimes  the  injection  of  scopolamin  brought  relief. 

Two  cases  of  shell  shock  with  unconsciousness  are  described  in  which  an  un- 
usual manifestation  was  observed — a  peculiar,  slow  movement  of  the  head  result- 
ing in  a  forced  position  resembling  that  seen  in  torticollis.  An  interesting  case 
history  of  functional  motor  disturbance  following  heat  stroke  is  cited.  This  pa- 
tient, immediately  after  his  stroke,  was  seized  with  spasms  of  the  arms  and  tremors 
of  the  legs.  The  position  and  action  of  the  arms  was  very  curious.  They  were 
bent  at  right  angles  at  the  elbow  across  the  chest,  and  then  violently  extended. 
This  motion  was  continuous  and  so  rapid  that  there  were  220  flexions  and  ex- 
tensions per  minute,  or  198,000  during  the  fifteen  waking  hours.  In  sleep  they 
ceased.     The  whole  body  and  head  were  involved  in  the  shaking  motion. 

Epilepsy  was  not  often  found.     A  case  is  described. 

The  nervous  pathologj^  of  shock,  particularly  shell  shock,  is  discussed  in  de- 
tail. Among  psychic  causative  factors  are  consciousness  of  danger,  seeing  a 
comrade  suft'er  a  horrible  death,  and  many  other  conditions  and  events  of  modern 
warfare.  Organic  causes  are  the  tremendous  atmospheric  pressure  caused  by  the 
explosion  of  the  shell,  the  poisonous  gases  liberated  from  it,  and  the  concussion  of 
the  whole  body  and  skull  in  cases  in  which  the  man  is  thrown  down  violently  or 
blown  up  or  against  some  fixed  object,  such  as  a  tree  or  wall.  Physical  and  men- 
tal exhaustion  may  produce  a  condition  of  susceptibility  to  shell  shock,  but  it  also 
occurs  in  strong-nerved  men.  In  nearly  all  cases,  the  initial  shock  is  followed  by 
a  period  of  unconsciousness  of  longer  or  shorter  duration.  Sometimes  no  nervous 
consequences  follow  and  the  men  continue  in  the  service.  Symptoms  in  those 
nervously  affected  are  vertigo,  impaired  hearing,  headache,  increased  excita- 
bility of  the  heart  and  of  the  muscles,  vasomotor  disturbances  and  hyperemotional 
states.  Other  cases  showed  neurasthenic  symptoms,  such  as  trembling  of  the 
tongue  and  fingers,  hypochondria,  depression,  etc.  Hysteriform  symptoms  were 
exhibited  by  others,  such  as  functional  paralysis  of  both  arms,  trembling  of  the 
whole  body  accompanied  by  spasms,  head  movements  and  facial  tics.  Deafness, 
mutism  and  aphonia  were  frequent.     Speech  disturbances  are  discussed  at  length. 

The  writer  concludes  his  article  by  brief  comments  upon  nervous  affections 
caused  by  shots  through  the  head,  and  upon  peripheral  paralysis. 

Westphal,  A.,  and  Hiibner,  A.  H.  Nervous  and  Mental  Diseases  in 
the  War  (tjber  nervose  und  psychische  Erkrankungen  im  Kriege) 
Med.  Klin.,  Berlin,  ii:  381-84  and  413-17,  April  4  and  11,  1915 

The  writers  believe  that  there  are  no  real  war  neuroses  nor  psychoses — that 
these  affections  are  not  essentially  different  from  those  observed  in  times  of 


35  • 

peace.  There  is  a  difJerence  of  opinion  as  to  the  frequency  of  these  so-called 
war  neuroses  and  in  order  to  make  this  question  somewhat  clearer  they  have 
collected  data  from  which  the  following  clinical  cases  may  be  cited. 

1.  The  patient  had  previously  been  healthy  and  free  from  mental  or  nervous 
disorders.  He  was  exposed  to  shell-fire  for  a  long  time.  After  the  near-by 
explosion  of  a  shell,  he  was  buried  alive  under  the  soil.  From  that  time  on  he 
suffered  from  headaches  and  for  a  period  was  mentally  unbalanced.  At  this 
time  he  received  news  of  his  captain's  death,  upon  which  he  was  seized  with  an 
acute  attack  of  excitement  and  delirium,  during  which  he  rolled  on  the  floor 
and  smashed  everything  in  his  proximity.  He  was  admitted  to  the  hospital 
in  a  condition  of  stupor  with  alternating  catatonia.  After  a  long  sleep  the  symp- 
toms cleared  up,  but  retrograde  amnesia  covering  a  period  of  several  weeks 
persisted.  He  remembered  nothing  of  his  captain's  death  and  subsequent 
events,  and  kept  complaining  of  headaches.  He  was  abnormally  sensitive  to 
noise  and  had  visual  illusions,  general  hyperesthesia,  and  complete  ageusia. 

2.  Patient  was  a  volunteer.  Nothing  was  known  of  his  heredity,  but  he  had 
always  been  healthy.  His  shoulder  was  grazed  by  a  shrapnel  piece  but  no 
serious  injury  resulted.  He  lost  consciousness  and  on  the  next  day  became 
delirious.  He  would  leap  up  suddenly  at  night  and  run  shooting  toward  the 
French  trenches.  At  another  time  he  shot  towards  the  ceiling  and  cried,  "The 
Russians  are  coming."  He  remained  in  this  condition  for  two  days.  He 
suffered  at  first  from  paralysis  of  the  right  arm  and  leg,  which  later  was  re- 
stricted to  the  arm  only.  He  also  complained  of  headaches.  He  confabulated, 
raved  at  night  of  his  war  experiences,  and  at  times  was  hysterical.  There  was 
complete  amnesia  and  hj'peresthesia  of  the  right  arm  and  shoulder,  but  no 
other  symptoms. 

3.  This  patient,  a  non-commissioned  officer,  was  very  excitable  but  otherwise 
healthy.  His  mother  was  very  nervous.  He  was  injured  in  his  foot  and  thigh, 
but  the  wounds  healed  quickly.  While  at  the  hospital  he  slept  badly  and 
dreamed  of  horrible  war  scenes.  When  he  first  attempted  to  walk  there  were  tics 
of  the  muscles  of  face  and  neck.  His  head  was  drawn  backward  and  sideways 
and  he  made  grimaces.  The  other  symptoms  were  marked  tremor  of  the  upper 
extremities,  sometimes  a  tremor  over  the  whole  body,  slight  hemi-hyperesthesia, 
very  active  tendon  reflexes,  vasomotor  disturbances  and  an  unsteady  gait.  He 
was  easily  influenced  by  suggestion. 

From  the  description  of  these  and  other  cases  the  wTiters  conclude  that 
clinical  pictures  of  nervous  disease  among  combatants  vary  greatly,  and  that 
they  are  by  no  means  so  rare  as  has  been  sometimes  believed.  However  most 
cases  occurred  in  predisposed  individuals.  In  other  instances  predisposition 
could  not  be  proven.  The  explosion  of  shells  in  the  immediate  vicinity,  even  if 
no  physical  injury  results,  is  the  most  important  of  the  direct  etiological  factors 
of  nervous  diseases  in  the  war.  Shell-shock  has  such  a  powerful  effect  upon  the 
nervous  system  that  it  can  cause  severe  nervous  symptoms,  even  in  non-disposed 
individuals.  These  symptoms  are  both  of  a  hysterical  and  neurasthenic  nature. 
Among  the  former  are  abasia,  paralysis  of  the  extremities,  tremors,  and  dis- 
turbances of  speech.  The  various  neurasthenic  symptoms  are  headache,  vertigo, 
insomnia,  vaso-motor  disturbances  and  tachycardia.  Some  cases  exhibit  pecul- 
iar contractures  of  the  muscles  of  the  neck,  conditions  of  utter  exhaustion  and 
general  and  sometimes  a  localized  sensory  hyperesthesia,  often  of  a  lasting 
nature.  A  combination  of  these  symptoms  results  in  the  various  forms  of  the 
clinical  picture  of  traumatic  neurosis.  The  prognosis  of  the  traumatic  war- 
neurosis  seems  more  favorable  than  that  of  the  pension  neurosis.  The  number 
of  cases  of  true  psychoses,  apart  from  cases  of  general  nervous  disturbances,  and 
the  "border-line"  cases,  was  very  small. 

The  types  of  war  psychoses  were  practically  the  same  as  tliose  in  times  of  peace. 
In  the  manic  and  depressive  cases  there  was  a  peculiar  tendency  to  activity. 


36 

coexistent  with  loss  of  self-confidence,  and  a  state  of  acute  fear  combined  with 
motoric  unrest  and  insomnia.  A  few  of  these  cases  resembled  dementia  precox 
and  sometimes  symptoms  were  observed  corresponding  to  those  of  acute  delir- 
ium. Men  who  had  never  displayed  psycliic  or  somatic  disturbances  of  any 
kind  at  times  showed  the  paralytic  and  tabetic  symptoms  of  metasyphilis. 

The  writers  then  take  up  the  medico-legal  work  of  the  psychiatrist  in  military 
services. 

These  questions  frequently  arise : 

1.  Is  the  patient  fit  for  military  service.^ 

"2.  Is  he  entitled  to  claim  indemnity? 

S.  Is  he  responsible  for  misdemeanors  that  he  has  committed.^ 

The  wTiters  believe  that  the  authorities  should  make  every  effoit  to  keep  men 
that  are  unfit  for  military  service  out  of  the  army.  Strict  examinations  should 
always  be  made,  both  of  those  who  themselves  claim  to  be  unfit  and  of  those 
who  laud  their  health  because  of  a  desire  for  enlistment.  Medical  officers  at 
the  draft  examination  are  not  always  at  fault  when  mental  disturbances  are 
overlooked.  The  consultation  of  all  available  records  of  insane  asylums  and 
similar  institutions  as  well  as  prophylactic  measures  should  prevent  such 
occurrences.  The  parents  of  boys  suffering  from  diseases  that  make  them 
undesirable  for  military  service  should  be  notified.  Diagnosis  is  comparatively 
easy  in  cases  of  paralysis,  dementia  precox,  amentia,  paranoia,  mania  and 
melancholia.  The  service  of  moderately  severe  cases  of  neurasthenia  and  hys- 
teria is  always  doubtful.  For  example,  several  cases  of  hysteria,  after  being 
honored  for  their  valor,  and  at  times  decorated  with  the  Iron  Cross,  subsequently 
suffered  complete  mental  breakdown  and  only  a  few  could  be  returned  to  the 
front.  Employment  behind  the  lines  should  be  given  in  such  cases.  Cases 
afflicted  with  spasms,  especiallj^  hysterics,  have  been  frequently  looked  upon  as 
malingerers,  although  various  symptoms,  such  as  fits  and  analgesia,  were  present. 
The  number  of  real  malingerers  is  not  great. 

The  majority  of  cases  that  claimed  indemnity  belonged  to  the  accident  neu- 
roses group.  Claims  were  not  granted  until  very  detailed  histories  of  patients 
were  obtained.  This  was  an  important  point,  since  cases  were  found  that  had 
already  tried  to  gain  compensations  from  various  companies  and  had  failed,  after 
which  they  tried  to  obtain  compensations  from  the  military  authorities. 

The  treatment  of  cases  suffering  from  neurasthenia  and  hj^steria  frequently 
gave  good  results.  The  patients  were  sent  out  of  the  clinic  as  quickly  as  pos- 
sible and  made  to  resume  their  former  occupation.  This  saved  many  from  per- 
manent incapability  of  work. 

The  writers  were  called  upon  in  twenty-three  cases  to  state  their  opinions  in 
the  legal  procedure  against  enlisted  men.  The  offenses  that  were  committed 
had  occurred  mostly  in  the  interior.  The  non-military  offenses  were  seven 
thefts,  one  embezzlement,  one  case  of  immorality,  one  case  of  libel,  and  one  case 
of  wearuag  the  Iron  Cross  without  being  entitled  to  it.  Among  the  military 
offenses  were  ten  cases  of  desertion,  two  of  lack  of  respect  to  superiors,  one  of 
insult  to  superiors,  two  of  assault,  three  of  misuse  of  weapon,  and  one  of  coward- 
ice. None  of  these  could  be  termed  healthy  in  a  clinical  sense.  Alcohol  was 
frequently  a  causal  factor  in  these  offenses.  Psychopaths  who  had  been  de- 
prived of  alcohol  for  a  long  time  became  much  excited  after  taking  a  few  glasses 
of  wine.  Total  abstinence  would  be  the  most  desirable  thing  but  it  is  hardly 
possible  to  enforce  this  in  a  large  army.  It  is  important,  however,  that  the 
superior  officers  keep  an  eye  on  those  who,  in  a  state  of  intoxication,  are  liable 
to  cause  trouble.  After  a  prolonged  period  of  abstinence  only  small  doses  of 
alcohol  should  be  allowed. 

Several  interesting  cases  in  which  alcohol  was  responsible  for  the  patients' 
offenses  are  described.  One  is  cited  here.  The  patient's  two  brothers,  his 
father,  his  father's  two  brothers,  and  his  great  uncle  were  heavy  drinkers. 


37 

nearly  all  of  them  having  shown  signs  of  delirium.  His  mother  had  fits  as  a 
child.  The  patient  himself  had  gone  to  school  only  occasionally,  and  then  was 
troublesome  to  his  teachers  and  rude  and  brutal  to  his  classmates.  He  also 
committed  thefts.  After  he  left  school  he  had  several  positions  as  an  appren- 
tice, but  he  never  learned  any  trade.  He  left  these  positions  and  was  finally 
employed  as  an  unskilled  laborer,  but  was  again  discharged  because  of  his 
irritability.  He  then  enlisted  in  the  army.  Here  he  got  eighty-five  days  of 
confinement  for  disciplinary  offenses.  He  was  convicted  sixteen  times  for  brutal 
acts,  burglary,  thefts,  insults,  public  misdemeanors  and  exliibitionism.  Ob- 
servation showed  that  he  had  a  continuously  sullen  temper,  was  irritable  and 
inexact  in  his  statements,  that  he  slept  badly,  stammered  and  showed  many 
signs  of  degenerac3\  He  was  tried  for  desertion  and  afterwards  made  two 
attempts  to  escape.  At  the  time  of  committing  these  offenses  he  was  without 
exception  under  the  influence  of  alcohol.  He  admitted  that  he  was  very 
sensual  and  felt  forced  to  masturbate  immediately  after  taking  alcohol,  which 
caused  him  to  commit  his  sensual  offenses.  The  writers  suspected  this  to  be  a 
case  of  epilepsy  but,  as  the  patient's  statements  were  very  unreliable,  notliing 
further  could  be  diagnosed.  This  case  shows  how  difficult  it  sometimes  was  to 
come  to  a  definite  conclusion.  The  writers  state  that  in  cases  of  apparent 
desertion  like  the  above,  the  court  always  assumed  that  they  acted  so  only  tem- 
porarily, and  sentenced  them  accordingly. 

Redlich,  Emil.  The  War  and  the  Nervous  System  (Einige  allgemeine 
Bemerkungen  iiber  den  Krieg  und  unser  Nervensystem)  Med. 
Klin.,  Berlin,  ii :  469-73,  April  25,  1915 

The  writer  docs  not  discuss  organic  injuries  of  the  nervous  sj^stem  but  limits 
himself  to  the  question  of  the  degree  of  resistance  of  the  human  nervous  system 
during  war  time.  He  believes  that  our  age  is  one  of  increased  capability 
and  nervous  resistibility  and  that  there  is  no  justification  in  speaking  of  a 
progressive  degeneration  of  the  civUized  nations.  Two  factors,  however,  are 
worthy  of  attention.  Insomnia,  especially  among  peasants  who  had  never 
before  known  anything  of  sleeplessness,  was  very  frequent.  Dreams  about  war 
scenes  seemed  to  disturb  their  sleep.  There  was  also  variation  of  body  tem- 
perature and  of  heart  action  apparently  without  adequate  cause. 

The  writer  believes  that  in  cases  where  a  compensation  does  not  come  into 
consideration,  a  comparatively  small  number  of  wounded  soldiers  develop 
"traumatic  neurosis." 

Shell  explosions  in  the  immediate  vicinity  are  one  of  the  most  frightful  of  war 
conditions.  Officers  have  reported  that  whole  companies  that  had  been  exposed 
to  shrapnel  showers  were  attacked  with  crying  fits,  vomiting  and  other  nervous 
conditions,  but  that  the  psychic  balance  was  re-established  as  soon  as  the  re- 
serves had  t^ken  their  places.  Even  in  cases  where  the  patient  had  been 
wounded  and  had  suffered  concussion  of  the  brain,  the  symptoms  of  a  traumatic 
neurosis  rarely  develop.  Another  point  of  importance  is  that  traumatic 
neurosis  is  a  relatively  benign  condition. 

The  writer  corroborates  Oppenheim's  statement  that  sj'mptoms  of  traumatic 
neurosis  often  developed  as  an  immediate  consequence  of  the  trauma  even 
before  the  wish  had  a  chance  to  take  effect. 

The  prognosis  of  the  traumatic  neurosis  is  much  more  favorable  now  than  in 
times  of  peace.  This  is  ascribed  to  two  facts:  (1)  The  patients  are  young  and 
healthy;  (2)  The  incentive  for  obtaining  a  disability  compensation  is  stronger 
in  times  of  peace  than  now.  Besides,  if  the  patient  is  resigned  to  the  thought 
that  h(;  will  be  compelkvl  to  return  to  the  front,  whether  or  not  the  nervous 
disorders  have  disappean'd,  he  makes  astonishingly  rajjid  progress.  This  is 
especially  true  of  traumatic  neurosis  in  which  hysterical  symi)toms  predominate. 


38 

particularly  in  organic  lesions  of  the  nervous  system.  Therapeutic  methods 
however  are  questionable  because  of  their  severity  and  painful  nature.  Many 
cases  of  hysterical  paralysis  and  anaesthesia,  tremors,  peculiar  astasias  and 
abasias,  which,  under  ordinary  treatment  remained  uninfluenced  for  months, 
have  been  cured  in  a  single  sitting  by  the  application  of  a  strong  faradic  current. 
It  goes  without  saying  that  this  form  of  treatment  removes  the  symptoms  but 
not  the  hysteria.  Isolation  and  a  milk  diet,  added  to  this  method,  have  given 
good  results.  Such  cases  are  sometimes  considered  malingerers,  but  many 
authorities  maintain  that  genuine  malingering  is  very  rare;  it  is  one  of  the 
symptoms  of  traumatic  neurosis.. 

The  writer  believes  that,  in  cases  of  traumatic  neurosis  with  neurasthenic 
symptoms,  predisposition  is  an  important  factor.  Explosions,  hardships  and 
scenes  of  terror,  or  injuries  may  cause  the  outbreak  of  the  latent  condition.  On 
the  other  hand,  acute  exhaustion  neurasthenia  is  very  rare. 

The  treatment  of  neurasthenia  is  totally  different  from  that  of  cases  of  hysteria. 
Many  have  been  cured  by  a  complete  change  of  environment.  Spontaneous  or 
miraculous  cures  of  neurasthenia  are  not  possible.  The  psychological  factor 
in  the  treatment  is  of  the  greatest  importance.  The  patient  must  be  convinced 
that  his  troubles  have  no  organic  basis,  that  his  mere  dislike  of  service  at  the 
front  is  not  a  sufficient  reason  for  declaring  him  unfit  for  such  service,  that  his 
stay  at  the  hospital  is  only  for  the  purpose  of  increasing  his  resistance  to  disease. 

The  writer  has  met  several  cases  of  depression,  particularly  in  soldiers  who 
were  worried  about  their  families  left  in  the  regions  occupied  by  the  enemy.  He 
has  also  observed  cases  of  schizophrenia,  that  became  acute  during  the  war, 
confusional  states,  progressive  paralysis  and  alcoholic  psychoses. 

The  rest  of  the  article  deals  with  the  influence  of  the  war  upon  the  civilian 
population  in  regard  to  mental  and  nervous  diseases.  A  few  interesting  cases 
are  cited. 

Marburg,  Otto.    Neurology  in  War  (Neurologic   im   Kriege)    Jahr. 
.    fiir  artz.  Fortbild.,  Munich,  May  1915,  p.  1-14 

In  modern  warfare,  injuries  of  the  brain  and  of  the  peripheral  nerves  are  more 
frequent  than  they  have  been  in  former  wars.  The  recent  progress  in  surgery, 
however,  gives  scope  for  greater  attention  to  such  injuries  and  also  to  those  of 
the  spinal  column.  Only  the  skilled  surgeon  can  perform  these  operations,  but 
the  neurologist  is  constantly  needed  for  consultation  and  assistance. 

Bullet  shots  grazing  the  skull  and  injvu-ing  the  skin  without  affecting  the  bony 
structure  are  important  only  in  as  much  as  the  clinical  pictm-es  resulting  from 
them  resemble  "concussion"  neuroses.  When  the  bullet  strikes  him,  the  soldier 
falls  to  the  ground,  remains  unconscious  for  a  few  moments,  vomits  and  has  a 
short  period  of  amnesia.  This  is  therefore  a  typical  pictm-e  of  concussion  of  the 
brain.  A  few  days  later  the  patient  is  somewhat  apathetic  and  nauseated,  com- 
plains of  headache  and  his  pulse  is  slow.  Improvement  takes  place  after  an 
interval  of  from  eight  to  fourteen  days  of  rest,  but  the  headaches  and  the  low 
pulse  rate  may  persist  for  weeks.  X-rays  are  absolutely  essential  since  the  inner 
table  may  not  always  escape  injm-y.  These  shots  are  frequently  accompanied 
by  conditions  of  stupor  or  clinical  pictures  resembling  Korsakoff's  psychosis,  or 
followed  by  nem-asthenia  and  hypochondriasis.  The  prognosis  is  generally 
favorable  and  the  treatment  which  consists  in  strict  confinement  to  bed,  at  least 
until  the  pulse  is  normal,  rarely  lasts  more  than  four  weeks. 

Tangential  shots  always  necessitate  operations.  Even  if  they  only  injure  the 
bone,  the  splinters  in  the  inner  table  cause  lesions  of  the  brain.  Infections, 
abscess  formations  or  encephalitis  often  follow.  In  the  beginning,  the  clinical 
pictures  resemble  those  of  the  grazing  shots.  Here  also  there  is  concussion  of 
the  brain,  slow  pulse  and  headaches,  but  along  with  these,  there  are,  according  to 
the  location  of  the  lesion,  paresis,  paraplegia,  aphasia  and  hemianopsia.     The 


absence  of  irritation  phenomena  even  where  motor  areas  are  involved,  is  very 
striking.  Paraplegia  was  for  the  most  part  flaccid  with  increased  reflexes  and 
the  presence  of  Babinski  and  Oppenheim  signs.  The  brain  abscesses  resulting 
from  these  shots  are  usually  accompanied  by  an  exceedingly  subnormal  tempera- 
ture at  about  35.9°  C,  bradycardia  (pulse  52)  and  marked  moroseness.  At  times 
there  was  a  rise  in  temperatm-e  and  leukocytosis  preceding  the  abscess  formations. 
An  X-ray  examination  is  absolutely  essential  in  gaining  a  clear  picture  of  the 
extent  of  the  lesion.  The  prognosis  in  tangential  shots  is  comparatively  favor- 
able, if  unaccompanied  by  brain  abscesses.  The  fatality  is  usually  one  in  thir- 
teen compared  to  brain  abscesses  where  there  are  eight  fatal  cases  out  of  every 
eleven.  Surgical  treatment  is  almost  always  necessary  even  if  it  may  have  to  be 
postponed  for  a  period  of  two  or  three  weeks.  Spontaneous  cures  are  possible, 
though  in  such  cases  there  is  likely  to  be  a  later  abscess  formation. 

When  the  projectile  remains  in  the  bony  substance  or  the  brain  matter  the 
injuries  may  be  classed  as  either  superficial  or  deep-seated.  The  symptoms  re- 
sulting from  the  superficial  shots  are  identical  with  those  of  the  tangential  shots. 
Brain  abscesses  usually  form  in  front  of  the  bullet.  In  such  cases  an  operation 
is  advisable  and  the  prognosis  is  favorable  but  an  X-ray  examination  is  essential 
in  diagnosis.  Sometimes  there  are  no  symptoms  except  the  initial  slight  con- 
cussion, and  on  one  such  occasion  a  soldier  refused  to  be  sent  to  the  hospital, 
remaining  at  the  front  for  eight  days,  when  he  showed  symptoms  of  a  brain 
abscess.  Surgical  treatment  is  not  to  be  used  in  the  case  of  these  deep-seated 
shots  for  the  abscess  formation  has  usually  penetrated  the  ventricles,  leading  to 
pyocephalus,  meningitis,  etc. 

Penetrating  shots  that  leave  the  brain  may  do  so  either  at  a  distance  of  not 
more  than  a  few  centimeters  from  the  entrance — these  are  known  as  segmental 
shots — or  they  may  traverse  the  brain  in  a  sagittal  or  frontal  direction,  in  which 
case  they  are  called  penetrating  shots  proper.  Lesions  of  the  latter  tj^e  are 
very  frequent  but  the  symptomatology  varies.  There  are  cases  in  which  no  clin- 
ical symptoms  exist  after  the  initial  concussion  and  the  accompanying  general 
symptoms.  Then  again,  regional  symptoms  in  others  are  very  marked.  The 
prognosis  on  the  whole  is  favorable  provided  there  is  no  infection.  Operations 
are  absolutely  contra-indicated. 

In  cases  of  the  segmental  shot,  the  symptomatology,  prognosis  and  treatment 
are  the  same  as  for  cases  of  tangential  or  superficial  shots.  A  few  cases  may  be 
cited.  One  shot,  penetrating  both  mastoid  processes  directly  behind  the  ear, 
caused  cerebellar  affections  with  peculiar  disturbances  of  speech.  Another  shot, 
entering  somewhat  higher,  caused  cortical  blindness.  Still  another,  entering 
near  the  left  eye,  and  leaving  beliind  the  right  ear,  caused  the  clinical  picture  of 
bulbar  paralysis  of  the  right  side. 

The  most  important  complications  of  brain  shots  are  pyocephalus,  meningitis, 
cerebral  hernia,  ventricular  fistula  and  cerebral  prolapse.  A  sudden  rise  of  tem- 
perature to  40°  C,  a  rigidity  of  the  whole  body  musculature  and  a  decrease  of  the 
pulse  rate  generally  indicate  a  rupture  of  the  ventricle.  Basal  meningitis  with 
cranial  nerve  involvement  soon  follows,  but  often  disappears  as  rapidly.  This 
picture  generally  corresponds  to  pyocephalus,  the  infection  finding  its  way  most 
likely  through  the  foramen  of  Magendie.  It  is  striking  that  the  side  away  from 
the  convex  part  of  the  bullet  lesion  was  always  the  most  largely  involved.  The 
question  as  to  whether  spinal  puncture  is  necessary  to  relieve  meningeal  compli- 
cations must  be  left  open,  for  in  two  cases  a  cure  was  affected  without  it.  The 
prognosis  of  ventricular  fistula  is  favorable,  the  treatment  consisting  in  absolute 
rest.  Cerebral  prolapse,  the  most  frequent  complication  of  brain  shots,  is  due 
to  a  congestion  and  edema  caused  by  infection.  Another  causative  factor  may 
be  the  premature  transportation  of  the  patient.  The  prognosis  is  favorable  but 
the  regional  symptoms  are  mostly  of  a  more  permanent  character,  and  disappear 
only  when  the  herniae  recede.     There  are  also  primary  prolapses  caused  by  the 


40 

shot  itself.  In  these  eases,  surgical  interference  is  contra-indicated  since  the 
symptoms  generally  disappear  after  a  few  days. 

Rest  is  the  most  essential  feature  in  the  treatment  of  such  cases.  A  very  sim- 
ple remedy  consists  in  the  local  application  of  tincture  of  iodine.  Pock  forma- 
tion and  the  retention  of  even  the  smallest  quantity  of  secretions  must  be  pre- 
vented. 

The  ratio  between  brain  shots  and  spinal  column  shots  is  1  to  6.  Those  caus- 
ing lesions  of  the  spinal-marrow  indirectly  are  (1)  bullet  shots  penetrating  the 
thorax  or  arrested  in  the  thorax  (2)  grazing,  penetrating  or  arrested  shots  in  the 
spinal  column  (3)  shots  arrested  m  the  spinal  column  (4)  shots  penetrating  the 
spinal  marrow.  The  clinical  picture  resulting  is  known  as  "commotio  medullae 
spinalis",  where  commotio  implies  a  tearing  of  lymphatic  capillaries.  Tliis  re- 
sults in  the  formation  of  edematous  traumatic  degeneration,  etc.,  which  in  turn 
may  cause  symptoms  that  correspond  to  a  tj'pical  lesion  of  the  spinal  column. 
The  term  "commotio  medullae  spinalis "  is  not  very  definitive.  It  is  used  mostly 
in  connection  with  symptoms  occurring  after  a  heavy  fall.  Immediately  after 
the  accident,  the  patient  shows  paralytic  weakness  of  the  extremities  but  re- 
covers without  treatment  in  the  course  of  three  or  four  weeks.  Tliis  is  not  a 
functional  disturbance  but  one  of  an  organic  nature,  since  an  increase  in  reflex 
and  urinary  symptoms  clearly  indicates  definite  anatomical  lesion  of  the  spinal 
marrow.  Sorhe  of  the  striking  features  in  the  clinical  pictures  resulting  from 
these  shots  may  be  mentioned.  The  symptoms  appear  directly  after  the  injury. 
At  first  there  is  usually  flaccid  paralysis,  but  after  a  few  days  it  often  becomes 
spastic,  sometimes,  however,  remaining  flaccid  for  months  even  if  the  lesion  is 
far  above  the  centers  responsible  for  the  paralysis.  A  lesion  in  the  cervical 
region  causes  flaccid  paralysis  of  the  upper  and  spastic  paralysis  of  the  lower  ex- 
tremities. Atrophy  of  the  muscles  of  the  hand,  rectal  and  bladder  disturbances 
and  decubitus  occur  very  early.  The  sensory  disturbances  are  the  same  that 
we  get  in  a  transverse  lesion  of  the  cord.  Above  the  anesthetic  zones  there  is 
generally  a  small  zone  of  hyperalgesia,  seldom  involving  the  whole  of  one  or  two 
segments.  In  lesions  of  the  dorsal  region  we  get  a  flaccid  paralysis  of  the  lower 
extremities.  Lesions  in  the  lumbar  region  often  produce  loss  of  patellar  and 
Achilles  reflexes  with  no  involvement  of  bladder  and  rectum,  flaccid  paralysis 
of  the  lower  extremities  and  corresponding  sensory  disturbances.  The  Brown- 
Sequard  syndrome  is  frequently  present.  Tenderness  upon  pressure  over  the 
spinal  column  and  spontaneous  root-pain  is  very  rare.  Five  or  six  weeks  suffice 
to  show  clearly  the  possibilities  for  cm-e.  The  latter  two  conditions  indicate 
surgical  procedures.  Patients  with  a  flaccid  paralysis  that  has  lasted  tliree  or 
four  months  are  frequently  able  to  use  their  legs  spontaneously  a  few  weeks  after 
the  operation.  Decubitus  and  cystitis  do  not  contra-indicate  operations  unless 
the  lesions  are  of  a  very  severe  nature.  Pulmonary  and  abdominal  complica- 
tions do,  however,  call  for  surgical  treatment. 

Injiu-ies  of  the  facial  nerves  caused  by  bullet  shots  are  most  frequent.  There 
were  two  cases  of  facial  paralysis,  however,  that  seemed  to  be  of  rheumatic  origin. 

The  peripheral  nerves,  especially  the  radial  and  the  peroneal,  are  involved  in 
injiu-ies  of  the  extremities.  A  striking  feature  in  these  cases  is  the  relative  ab- 
sence of  pain,  even  when  sensory  nerves  are  injured.  Sensory  disturbances  are 
slight  compared  with  motor  disturbances.  The  atrophic  processes  seem  to 
occur  later  than  is  usually  the  case.  Trophic  and  vasomotor  disturbances  are 
common  and  extensive.  Other  symptoms  are  coldness  of  the  limbs,  cyanosis, 
hj'peridrosis,  hj'perkeratosis  and  changes  in  the  hair  and  nails.  Nerve  lesions 
are  generally  complicated  by  extensive  suppuration  and  therefore  the  conse- 
quent callus  and  connective  tissue  formations  make  surgical  operations  very 
diflBcult  after  a  healing  process  of  several  weeks. 

The  best  time  to  operate  is  in  complete  absence  of  any  degenerative  reaction. 
It  might  also  be  advisable  to  use  surgical  methods  when  a  slight  reaction  has 


41 

started  but  has  been  stationary  for  a  long  time.  An  early  operation  is  best. 
Slight  improvements  may  sometimes  remain  stationary  and  then  cause  very 
irritating  contractures.  A  trial  of  two  or  tlu-ee  months  is  sufficient  however,  to 
show  whether  an  operation  is  needed  or  not.  Palpation  of  the  nerve  for  the 
purpose  of  diagnosis  has  been  recommended  in  order  to  determine  whether  or 
not  it  has  been  severed  by  the  shot. 


Hartmann,  Fritz.  Training  Schools  for  "Brain-Cripples"  (Ubung- 
schulen  fiir  Gehirnkriippel)  Miinch.  med.  Woch.  62 :  769-70, 
June  8,  1915 

A  large  percentage  of  cases  of  brain-injury  in  the  present  war,  after  more  or 
less  extensive  treatment,  are  discharged  as  "surgically"  cured  but  only  a  few 
of  these  are  organically  and  functionally  cured.  All  the  rest  may  be  classed  as 
"brain-cripples".  As  a  result  of  surgical  interference  in  many  of  these  cases, 
even  if  no  organic  lesions  remain,  there  are  permanent  functional  disturbances, 
either  of  a  motor,  psychomoter,  or  sensorj-motor  nature.  These  cases  are  dif- 
ferent from  those  occurring  in  times  of  peace  when  most  of  the  cases  in  hospitals 
for  mental  diseases  are  degenerate  types.  The  war  sufferers  were  young,  strong 
and  healthy  at  the  time  of  the  injury. 

Therapeutic  methods,  too,  are  different  in  both  instances.  In  the  ordinary 
cases  of  mental  disease  we  try  to  arrest,  to  limit  or  to  remove  the  underlying 
causative  factor,  whereas  in  the  case  of  the  so-called  brain-cripple  v,e  must  deal 
with  a  completely  healed  wound  in  the  brain.  The  scar  does  not  become  worse, 
no  matter  what  functional  disturbances  result  from  it.  Therefore,  the  brain, 
structurally  unchanged,  is  capable  of  being  restored  to  a  marked  degree.  Brain- 
areas  that  are  functionally  related  to  those  more  or  less  injured  adopt  the  func- 
tions of  the  latter  and  in  this  way  the  defect  is  practically  made  up  for.  The 
same  principle  also  holds  true  for  the  motoric  processes  in  the  extremities,  for  the 
motor  speech  apparatus  m  central  lesions  and  for  the  higher  senso-motoric 
functions  of  the  sensory  systems.  The  restoration  of  the  lost  or  incapacitated 
functions  should,  therefore,  be  the  first  therapeutic  aim  of  the  medical  profession. 
This  may  be  accomplished  by  means  of  reeducation. 

This  method  is  not  new,  for  it  is  being  used  in  the  treatment  of  various  other 
types  of  cases  such  as  abasia,  speech  defects,  and  hemiplegia.  The  new  schools 
for  the  training  of  orthopedic  cripples  also  use  the  same  method.  It  is  com- 
paratively new,  however,  as  applied  to  the  brain.  It  is  practised  by  a  special 
school  in  the  University  Clinic  at  Graz,  Austria.  The  aims  of  this  school  are  to 
arouse  or  create  anew  the  various  processes  of  perception,  apperception,  memory 
and  orientation,  to  reconstruct  the  faculty  for  apprehension  through  the  senses, 
to  overcome  defects,  to  do  away  with  pathological  associations  and  to  form  new 
ones  in  their  stead,  and  to  stimulate  the  power  of  abstract  conception.  This 
treatment  is  based  more  upon  the  pedagogical  than  upon  the  medical  skill  of  the 
leaders  of  this  school,  but  since  the  results  obtained  are  so  encouraging,  a  trial 
on  a  larger  scale  is  planned. 

Kastan,  Max.  Forensic  Psychiatric  Observations  in  the  Array  (Foren- 
sisch-psychiatrische  Beobachtungen  an  Angehorigen  des  Feld- 
heeres)  Deutsche  med.  Woch.,  Berlin,  41:734-37,  June  17, 
1915 

Psychiatrists  study  psychic  disturbances  occurring  in  the  army  so  as  to  dis- 
cover the  role  tTiat  predisposition,  bodily  exhaustion  and  over-exertion,  strong 
emotions,  and  other  conditions  of  army  life,  play  in  the  production  of  various 


42 

clinical  pictures.     Military  delinquents  often  exhibit  these  pictures,  so  for  this 
reason  are  frequently  subjects  of  careful  psychiatric  study. 

Extensive  work  along  this  line  has  been  done  by  such  men  as  Schultze,  Meyer, 
Monkeberg,  and  Craimer.  The  cases  described  by  them  uiclude  mostly  deser- 
tion, abandonment  of  post  of  duty,  disobedience  and  disrespect.  In  the  Konigs- 
berg  Clinic  about  fifty  such  cases  were  treated  up  to  February  1915.  Three  of 
these  were  officers,  seven  were  volunteers,  eight  regulars,  six  reservists,  seven- 
teen national  guardsmen,  a  few  belonged  to  the  medical  corps  and  the  rest  to 
other  divisions  connected  with  the  military  organization.  Out  of  these  fifty 
cases,  four  had  previously  been  dismissed  from  the  army,  two  of  these  on  account 
of  mental  defects,  five  had  been  in  asylums  for  inebriates  and  the  insane,  and 
fifteen  had  been  previously  convicted,  one  of  them  only  by  a  military  court, 
nine  by  a  civil  court  and  one  had  been  acquitted  on  the  strength  of  a  medical 
expert's  diagnosis  of  mental  deficiency. 

There  were  comparatively  few  cases  of  simple  psychic  disturbances  among 
those  that  came  under  observation.  Manic-depression  and  general  paralysis 
were  not  present  at  all.  There  were  eight  cases  of  dementia  praecox.  One  of 
these  was  accused  of  attacking  another  soldier  with  a  knife  During  the  eight 
weeks  he  was  under  observation  he  spoke  only  once  and  then  just  a  few  words. 
He  was  in  bed  most  of  the  time,  uttering  now  and  then  a  hoarse  laugh,  staring 
at  the  wall,  or  twisting  his  moustache.  Whenever  he  came  to  trial,  he  would 
put  his  hands  behind  his  back  as  he  did  when  he  was  arrested  and  tried  to 
conceal  the  knife.  Another  case  was  at  first  very  uncommunicative,  irritable 
and  excited.  Gradually  he  quieted  down  and  began  to  show  interest  in  his 
surroundings.  He  accused  his  wife  of  being  a  spy,  said  that  people  wished  to 
make  a  spy  of  him  while  on  post  duty,  and  thought  his  name  had  been  dishonored. 
He  had  entered  the  army  as  volunteer,  but  deserted  because  he  was  afraid. 
Another  case  of  dementia  praecox  attracted  attention  by  uprooting  shrubs  and 
trees  in  the  park  in  order  to  look  for  spies  and  enemy  shells.  He  had  invented  a 
process,  so  he  believed,  to  ozonize  the  "poisoned"  water  of  the  Konigsberg  water 
supply,  which  it  was  his  duty  to  guard.  He  also  imagined  the  presence  of  worms 
and  bacilli  in  every  glass  of  water.  Because  he  drew  plans  of  the  aqueduct,  he 
was  accused  of  betraj'ing  mihtary  secrets.  Another  case  wrote  many  letters 
to  the  authorities  discussing  the  political  situation  in  a  foolish  manner  and  was 
accused  of  lese-majesty.  Two  other  cases  had  deserted  and  committed  thefts 
at  the  same  time.     One  of  them  had  previously  suffered  from  kleptomania. 

There  were  nine  cases  of  low-grade  mental  defectiveness,  most  of  whom  were 
accused  of  desertion,  and  of  other  crimes  such  as  theft,  assault,  murder,  mutiny, 
etc.  One  man  stole  a  horse  from  a  peasant,  left  his  regiment  and  in  his  uniform 
went  to  a  small  town  where  he  was  known.  Another  case  was  sent  to  the  post- 
office  to  deposit  a  considerable  amount  of  money  and  at  the  same  time  to  look 
for  a  stolen  bicycle.  He  stayed  in  the  city,  depositing  the  money  after  several 
days.  When  he  was  arrested,  he  claimed  that  he  had  been  searching  for  the 
bicycle  in  a  distant  city.  His  liistory  showed  that  he  had  frequently  run  away 
from  home  and  that  he  had  often  been  convicted  of  fraud  and  embezzlement. 
In  the  case  of  these  defectives,  the  combined  effect  of  two  different  motives  was 
the  cause  of  their  desertion.  When  they  left  their  regiments  they  were  too  stupid 
to  find  their  way  back  and  then  were  overcome  by  fear  of  punishment  for  having 
stayed  away  so  long. 

The  degenerates  and  psychopaths  constituted  the  largest  group  of  cases, 
ranging  from  the  liighly  intelligent  but  emotionally  unstable  individual  to  the 
low-grade  criminal.  Most  of  these  had  previously  shown  some  forms  of  mental 
abnormality  and  had  been  inmates  of  institutions  for  the  mentally  diseased, 
prisons  or  reformatories.  Some  of  them  seemed  to  derive  great  pleasure  from 
decorating  themselves  in  the  most  bizarre  and  foolish  manner  with  crude  repre- 
sentations of  military   honors  and  insignia.     Tattooing  was  frequent.     They 


43 

often  made  a  practice  of  petty  and  sometimes  useless  thievery,  stealing  handker- 
chiefs, broken  tooth-brushes,  and  other  trivial  articles.  One  cadet  who  had  been 
recognized  as  a  psychopath  at  a  military  academy  and  therefore  dismissed, 
reenlisted  in  the  army  at  the  beginning  of  the  war.  After  being  slightly  wounded 
in  the  head,  he  was  sent  to  a  hospital.  Here  he  suffered  from  all  kinds  of  gran- 
diose delusions,  disappeared  when  he  was  well  enough  to  walk,  but  later  returned 
to  duty  and  spent  most  of  his  time  writing  poetry. 

One  patient  showed  clearly  Ganser's  syndrome.  Two  other  cases  of  hysteria, 
who,  in  states  of  utter  exhaustion  closely  resembled  psychopaths,  were  also 
accused  of  desertion.  Three  cases  of  epilepsy  were  charged  with  desertion,  when, 
after  an  absence  of  a  few  weeks,  they  again  reported  at  the  front,  one  of  them 
saying  that  he  had  been  in  Petrograd.  Several  alcoholics  were  accused  of  dis- 
respect, disobedience,  and  insult  to  superior  officers.  One  of  them  showed  a 
tjiJical  picture  of  complete  amnesia.  Another  had  killed  a  woman  because  he 
had  been  told  to  shoot  all  spies. 

From  these  observations,  the  writer  concludes  that  military  conditions  give  a 
certain  uniformity  to  all  criminal  acts.  Indi\'iduals  with  strong  emotions  and 
great  initiative  are  often  guilty  of  disobedience  and  disrespect  and,  where  these 
characteristics  are  lacking,  they  are  usually  deserters. 

WoUenberg,  R.  Occupation  Therapy  in  Military  Hospitals  for  Nervous 
Diseases  (Lazarettbeschaftigung  und  Militarnervenheilstatte) 
Deutsche  med.  Woch.,  Berlin,  41:  757-60,  June  24,  1915 

The  most  important  etiological  factor  of  nervous  diseases  is  predisposition 
involving  both  heredity  and  personal  experiences.  Thus  there  may  be  individ- 
uals by  heredity  endowed  with  a  labile  mental  equilibrium  who  lose  their  balance 
after  a  series  of  unusually  exciting  events.  In  the  treatment  of  such  cases, 
quieting  mental  influences  are  the  only  cure,  and  intelligent  and  useful  occupation 
is  the  most  important  of  these  influences. 

The  same  principle  must  be  applied  in  treating  patients  suffering  from  nerv- 
ous disturbances  in  war  time  since  their  cases  are  similar  to  those  in  times  of 
peace  with  regard  to  both  etiology  and  symptomatology.  This  fact  is  verified 
by  the  WTiter's  experience  in  that  all  cases  had  shown  signs  of  nervousness  before 
the  war.  The  occupation  selected  for  such  patients  should  be  useful  and  should 
make  them  more  contented.  Moreover,  no  man  should  be  forced  to  do  some- 
thing for  which  he  has  no  inclination  nor  should  he  be  made  to  do  work  calling 
for  over-exertion  on  his  part.  There  should  also  be  no  unfair  competition  with 
the  work  of  the  civilian  population.  A  well-chosen  occupation  can  make  the 
patient  stronger,  improve  his  general  condition,  arouse  self-confidence  and  in 
this  way  bring  about  mental  equilibrium.  All  forms  of  work  have  been  intro- 
duced such  as  wicker-work,  net-work,  fret- sawing  and  knitting  and  embroidering 
by  machine,  the  making  of  fishing  nets,  hammocks,  blankets  and  shoes  from 
remnants.  An  opportunity  for  heavier  liodily  work  is  also  afforded  in  the  car- 
penters' and  cabinet  makers'  shops  and  in  farm-work.  Business  courses  in 
typewriting,  stenography,  accounts,  etc.,  are  also  given. 

Entertairunent,  like  work,  is  an  important  factor  in  psychic  influence  and 
should  be  often  available.  In  the  hospital  there  are  various  facilities  for  this 
purpose,  the  gymnasium  with  all  its  opportunities  for  games  and  exercises  being 
an  attractive  center.  To  induce  the  men  to  take  part  in  these  exercises  various 
rewards  are  offered  such  as  better  rations,  personal  privileges,  freedom  from 
strict  supervision,  and  sometimes  small  money  prizes.  Formal  entertainments 
in  the  evening  such  as  concerts  and  recitals  are  not  enjoyed  so  much  as  the  light 
forms  of  entertainment  arranged  by  the  patients  themselves. 

Strict  discipline,  together  with  a  close  cooperation  of  attendants,  is  indispens- 
able for  success.     The  results  obtained  so  far  have  been  fairly  satisfactory  since 


44 

one-tliird  of  the  men  were  discharged  after  a  period  of  three  months.  The  writer 
beUeves  that  the  outlook  for  the  future  will  be  even  brighter  when  this  system- 
atic occupation  therapy  will  have  been  in  force  for  a  longer  period. 

Riebeth,  Neurasthenia   Among  Soldiers    (tJber  Neurac- 

thenie  bei  Kriegsteilnehmern)     Psych.-neurol.  Wcch.,  Hamburg, 
July  3,  1915,  p.  71-76 

The  statement  that  victory  in  a  war  of  to-day  will  go  to  the  nation  possessing 
the  strongest  nerves  has  been  made  many  times.  One  of  the  nervous  aflfections 
tending  most  to  lower  the  power  of  resistance  of  the  nervous  system  and  the 
physical  fitness  of  the  soldier  is  neurasthenia.  Observations  upon  2,526  soldiers 
treated  in  a  special  hospital  showed  that  neurasthenia,  next  to  hysteria  and  psy- 
choneuroses,  is  the  most  frequently  found  nervous  disorder.  True  psychoses 
are  comparatively  rare.  Neurasthenic  states  were  found  in  all  classes  of  the 
city  population  and  in  the  peasantry  but  were  not  frequent  among  the  profes- 
sional and  industrial  classes  of  large  cities.  The  etiological  factors  are  the  same 
in  war  as  in  peace,  although  the  clinical  pictures  were  somewhat  affected  by  war 
conditions.  These  causative  factors  may  be  of  a  psychical  or  physical  nature. 
A  strict  differentiation  of  the  two  can  rarely  be  made.  Usually  they  are  coexist- 
ent. Among  physical  causes  may  be  mentioned  over-exertion,  insufficient  sleep 
or  nutrition,  loss  of  blood  after  wounds,  fever,  pain,  suppuration  and  infectious 
diseases,  especially  tj-phoid  fever.  Among  psychical  causative  factors  are  the 
tremendous  nervous  strain  of  being  under  fire  in  long  battles  in  which  heavy 
artillery  now  plays  so  important  a  part,  the  continuous  effort  to  keep  the  atten- 
tion fixed,  the  frightful  scenes  of  the  battlefield,  mutilation  of  friends  and  com- 
rades, and.  last  but  not  least,  anxiety  and  worry  about  families  left  at  home  in 
probable  danger. 

The  writer  divides  the  symptomatology  of  neurasthenia  into  cerebral,  psychic, 
spinal,  gastro-intestinal,  cardio-vascular  and  sexual  manifestations.  He  groups 
neurasthenic  disorders  as  to  their  origin,  into  exogenous  and  endogenous  t\'pes. 
In  the  former  the  exciting  cause  is  an  injury  or  event  affecting  the  nervous 
system  of  mentally  healthy  individuals;  in  the  latter,  the  chief  etiological  factor 
is  nervous  insuflSciency  in  persons  with  a  congenital  predisposition.  The  exo- 
genous type  is  often  found  at  the  front  after  great  battles  and  also  at  hospitals 
in  the  interior  after  long  or  arduous  transportation  experiences. 

In  such  cases  the  clinical  picture  is  unvaried — apathy,  craving  for  rest  and 
sleep,  a  tendency  to  ill  humor  and  a  desire  to  be  let  alone.  More  severe  cases 
can  sleep  little  and  when  they  do  so  have  terrifying  dreams;  they  are  in  a  con- 
tinuous state  of  emotional  excitement  and  fancy  they  have  symptoms  of  all 
kinds  of  ailments.  Usually,  after  a  few  days  of  rest  and  suflScient  food,  a  normal 
state  of  mind  is  regained.  Cases  with  onset  before  the  war  are  not  necessarily 
of  endogenous  origin,  especially  in  men  who  have  done  over-strenuous  brain- 
work  and  so  are  likely  to  be  in  a  state  of  acquired  chronic  nervous  exhaustion. 

In  most  instances,  rest,  quiet  and  good  and  sufficient  food  will  bring  about  a 
complete  cure.  Therapeutic  measures  should  be  employed,  if  for  no  other  reason 
than  for  their  beneficial  psychic  effect.  These  should  be  limited  to  three  sittings 
a  week.  Hydrotherapy  in  all  its  forms  is  especially  important.  Diet  is  a  chief 
factor.  Treatment  by  electricity  may  be  used  to  advantage.  Cases  of  this  kind 
are  very  susceptible  to  psychotherapeutics,  in  which,  needless  to  say,  the  per- 
sonality of  the  physician  plays  a  most  important  part.  Very  nervous  patients 
should  always  have  a  private  room.  Two  months  should  be  the  limit  for  hos- 
pital stay. 

The  writer  lays  great  stress  upon  supplying  discharged  patients  with  suitable 
occupation.     Outdoor  work  is  the  best.     Sometimes  such  cases  may  be  sent 


45 

back  into  the  service  and  employed  at  the  rear  of  the  army.  Provision  should 
be  made  also  for  cases  unfit  for  any  kind  of  work  and  so  discharged.  Their 
condition  is  likely  to  become  serious  again  and  alcohol  is  often  an  easy  solace. 

Binswanger,  Otto.  Hystero-somatic  Symptoms  in  War  Hysteria  (Hys- 
tero-Somatische  Krankheitserscheinungen  bei  der  Kriegshys- 
terie)  Monat.  fiir  Psych,  u.  Neurol.  Berlin,  38:  1-60,  July  and 
Aug.  191 5 

The  article  is  based  upon  the  experience  of  the  writer  in  a  hospital  for  nervous 
diseases  during  the  first  seven  months  of  the  war. 

War  neurology  has  demonstrated  that  emotional  shock,  in  conjunction  with 
other  injuries,  may  cause  a  symptom  complex  identical  in  all  its  details  with  the 
well  known  chnical  picture  of  hysteria.  It  is  the  purpose  of  the  writer  to  show 
that  these  symptoms  may  develop  also  in  individuals  who  have  always  been 
perfectly  healthy  and  in  whom  no  neuropsychopathic  constitutional  anomalies 
can  be  demonstrated. 

In  many  cases  it  was  proved  that  excessive  physical  over-exertion  lasting  for 
weeks,  insufficient  food,  loss  of  sleep,  etc.,  had  lowered  the  power  of  physical 
resistance,  and  that  emotional  factors,  such  as  the  strain  caused  by  many  days 
in  the  trenches  under  continuous  shell-fire,  had  prepared  for  the  breakdown. 
Some  violent,  unexpected  psycliic  shock  was  all  that  was  necessary.  A  factor 
is  here  met  with,  which  is  not  characteristic  of  the  modern  conception  of  hysteria. 
In  the  majority  of  shell  shock  cases  the  patients  reported  having  been  blown  up 
often  as  high  as  ten  metres,  and  witnesses  confirmed  this  statement.  Some  said 
they  had  distinctly  felt,  before  they  lost  consciousness,  the  tremendous  atmos- 
pheric pressure  caused  by  the  explosion. 

Binswanger's  theory  is  that  the  mechanical  injury  of  distinct  sectors  of  the 
nervous  system,  which  takes  the  form  of  molecular  changes  within  injured  neu- 
rons, gives  the  clinical  picture  in  such  cases  its  distinctive  character.  In  con- 
firmation of  the  same  theory,  hysterosomatic  disturbances  were  found  in  func- 
tional regions  which,  Ijefore  the  war,  had  shown  pathological  affections.  Thus, 
hysterical  dysbasia  and  abasia,  with  or  without  tremor,  frequently  became  acute 
in  soldiers,  who,  before  the  war,  had  been  treated  for  debility,  tendency  to  fatigue, 
paresthesia,  etc.  Reports  of  a  number  of  interesting  cases  are  given  showing 
that,  in  states  of  war-hysteria,  new  hysterical  symptoms  may  appear  after  very 
slight  exciting  causes,  but  only  in  organs  previously  injured.  There  are,  how- 
ever, cases  in  which  no  such  process  of  preparation  nor  preexisting  organic  in- 
juries can  be  demonstrated,  and  in  these  the  violent  psycMc  shock  alone  must  be 
considered  the  etiological  factor. 

As  opposed  to  other  observers,  Binswanger  considers  hyperesthesia  and  anes- 
thesia, hyperalgesia  and  analgesia  the  most  important  symptoms  of  such  disorders 
as  found  in  peace  times,  and  that  their  mere  existence  forms  a  conclusive  diag- 
nosis unfler  such  coaditioJis;  however,  in  cases  of  war  hysteria,  hemianesthesia  or 
hemianalgesia  are  seldom  found  because  war  hysterics  are  rarely  constitutional 
hysterics. 

The  writer  next  discmsses  in  detail,  with  illustrations,  the  fact  that  sensory  and 
motor  disturbances  are  always  associated. 

Tremor  is  a  chief  symptom  of  hysteria  in  males.  Seventeen  case  histories  are 
reported  in  detail,  with  prognosis.  From  these  cases  the  author  draws  the  fol- 
lowing conclusions: 

1.  War  hysteria,  from  the  point  of  view  of  clinical  picture  and  hystero-somatic 
complex,  may  be  divided  into  two  chief  classes:  (a)  cases  in  which  family  and 
personal  histories  prove  a  pre-existent  hysteropatliic  constitution;  these  cases 
are  very  few  in  number;  (b)  cases  in  which  there  is  no  proof  of  predisposition. 


46 

2.  Cases  of  hysteria  have  developed  even  before  the  war  under  the  influence  of 
psychic  tension,  physical  exertion  and  minor  organic  diseases.  In  such  cases 
the  chief  etiological  factors  were  emotinal,  cerebral  or  spinal  shock,  and  toxic 
effects  of  noxious  gases.  Exciting  causes  of  both  groups  were  over-exertion, 
irregular  and  insufficient  nutrition,  loss  of  sleep  and  high  mental  tension. 

3.  The  hystero-somatic  clinical  pictures  developed  either  immediately  after 
the  onset  of  the  causal  factor,  or  after  a  period  of  incubation. 

4.  The  clinical  symptoms  of  groups  1  and  2  are  the  same.  However,  the 
most  varied  combinations  of  motor  sensory,  angio-neurotic  and  secretory  dis- 
turbances of  an  irritative  or  inhibitive  character  are  found.  The  most  frequent 
manifestations  are  tremors  of  aU  kinds,  shaking  dysbasias  and  astasias,  monople- 
gias, monoparesis  and  hemiparesis  with  contracture,  slight  spastic  conditions,  and 
finally  affections  of  the  pain-sensations. 

5.  The  theory  of  a  psychic  mechanism  as  the  origin  of  these  motor  and  sensory 
symptoms  is  not  demonstrable. 

6.  Proof  of  the  psychogenic  character  of  hystero-somatic  disturbances,  on  the 
other  hand,  can  be  deducted  from  the  success  of  the  therapeutic  methods  used  in 
treatment.  The  case  histories  previously  cited  show  that,  because  of  erroneous 
opinions  as  to  the  real  nature  of  the  trouble,  all  sorts  of  physical  and  medical 
treatment  proved  valueless.  When  finally  hydrotherapy  and  electrotherapy 
were  used,  it  was  always  as  suggestive,  not  physical,  agents.  Psychotherapy  was 
the  only  treatment  that  promised  to  be  generally  successful.  Gymnastic  exer- 
cises were  used,  not  only  to  increase  the  physical  health  of  the  patient,  but  also 
to  train  the  attention  and  the  will  power.  When  the  first  signs  of  improvement 
occurred,  to  the  regular  treatment  was  added  some  form  of  occupation  or  recrea- 
tion compatible  with  the  patient's  taste  and  education.  Keeping  the  patient 
busy,  restoring  his  self-confidence,  and  giving  sympathetic  encouragement 
brought  about  wonderful  results,  although  allowance  had  to  be  made  for  failures. 
Hysteria,  especially  aphonia,  is  the  most  stubborn  of  the  nervous  affections  to 
treat. 

Mann,  Ludwig.  Disturbances  following  Shell-Explosions  (Uber  Gra- 
natexplosionsstorungen)  Med.  Klin.,  Berlin,  ii :  963-64,  Aug.  29, 
1915 

There  is  always  a  question  as  to  the  nosological  conception  of  cases  resulting 
from  shell  explosions  in  all  discussions  of  this  subject.  This  is  undoubtedly  due 
to  the  confusing  nomenclature.  Some  writers  use,  the  term  "shell  contusion", 
and  others,  WoUenberg  and  Westphal,  speak  of  "shell  concussion".  These 
terms,  however,  apply  only  to  one  group  of  cases,  since  not  all  cases  are  charac- 
terized by  a  contusion  or  a  concussion.  The  individual  temperament  is  an  impor- 
tant factor  in  all  non  organic  conditions  and  this  accounts  for  the  great  variety  of 
clinical  pictures.  Other  factors  such  as  fatigue,  exhaustion  and  emotional  states 
are  also  present.  For  these  reasons  the  etiological  factor  only  should  be  consid- 
ered and  the  diagnosis  of  such  cases  should  be  expressed  as  "disturbances  follow- 
ing shell  explosions". 

Among  the  twenty -three  cases  observed  by  the  writer  of  mental  disorders  fol- 
lowing shell-fire  one  is  of  great  interest  in  as  much  as  the  emotional  state  pro- 
duced by  his  occupation,  namely,  that  of  digging  and  filling  military  graves,  was 
a  direct  cause.  These  feelings  resulted  in  a  condition  of  mental  dullness,  during 
which  he  did  not  react  to  any  external  impressions.  Even  while  his  condition 
was  improving,  the  mere  mention  of  war  was  suflBcient  to  cause  a  total  relapse 
into  his  former  state.  The  memory  of  the  olfactory  sensations  received  during 
his  occupation  was  very  painful  to  him. 

In  two  cases  only  was  alcohol  an  important  etiological  factor.  Conditions  of 
paralysis  were  very  frequent,  among  them  deafness,  mutism  and  deaf-mutism. 


47 

There  is  still  a  question,  however,  as  to  whether  or  not  the  actual  air  contusion 
and  detonation  are  to  be  regarded  as  direct  causes  of  these  conditions.  This 
question  is  influenced  by  the  fact  that,  in  most  cases,  no  apparent  lesions  exist 
and  psychotherapy  is  the  most  efficacious  treatment. 

In  two  cases  simple  treatment  of  the  laryngeal  region  with  the  faradic  current 
brought  speech  back.  Treatment  by  suggestion  cured  another  case  of  deafness. 
This  seems  to  demonstrate  that  these  disturbances  are  of  psychogenic  origin. 
There  was  also  a  case  of  paresis  of  both  legs  and  one  arm  following  immediately 
the  explosion  of  a  shell  but  without  any  organic  lesions.  In  two  cases  peculiar 
change  in  the  grammatical  use  of  language  was  observed.  The  men  talked  like 
children,  for  example,  "I  headache",  "I  not  well".  In  another  case  the  patient 
was  relieved  of  the  spasms  of  one  leg  and  tremors  by  any  involuntary  movement 
on  his  part. 

How  are  these  conditions  to  be  explained.?  In  some  cases  predisposition  could 
be  proved  but  not  in  the  majority.  Most  of  the  men  were  hardened  soldiers  who 
had  been  in  the  firing-line  more  than  once.  They  had  probably  been  through 
great  hardships  and  deprivations  and  were  in  a  condition  of  phj-sical  and  mental 
exhaustion,  or  they  were  in  a  state  of  maximum  mental  tension.  Under  such 
conditions,  the  explosion  makes  a  strong  and  deep  impression  and  remains  inti- 
mately connected  with  memory  of  the  accompanying  events. 

The  psychological  explanation  of  these  disturbances  is  only  a  matter  of  specula- 
tion. The  following  two  theories  may  be  suggestive:  (1)  An  outlet  for  the 
strongest  emotions  at  the  moment  is  presented  by  the  oncoming  unconsciousness. 
There  is  therefore  no  reaction  to  these  emotions  and  they  are  repressed.  (2) 
Normally  there  exists  an  inhibitive  mechanism  preventing  a  centripetal  stimulus 
from  being  transferred  to  the  centrifugal  paths.  This  stimulus  first  reaches  the 
higher  centers  in  order  to  cause  a  motor  innervation.  It  is  possible  that  by  a 
coincidence  of  particular  circumstances  such  as  exhaustion,  surprise,  fright,  ac- 
oustic impressions,  etc.,  a  centripetal  stimulus  of  great  strength  reaches  the  brain 
so  suddenly  that  the  inhibitive  mechanism  breaks  down,  thus  allowing  the  stim- 
vdus  to  reach  the  motor  tracks  and  so  prevent  a  normal  innervation. 

The  prognosis  in  purely  mental  disturbances  following  explosions  generally  is 
favorable  but  tnis  depends  on  the  predisposition  of  the  patient.  A  hysteric  will 
always  remain  a  hysteric.  In  a  case  of  temporary  monosymptomatic  hysteria, 
complete  rest  brought  about  a  cure.  A  correct  early  diagnosis  is  important,  how- 
ever, in  order  to  send  the  patient  to  a  special  hospital  without  any  loss  of  time. 

Hoffmann,  Rudolph.     Labyrinthine  Disturbances  (Detonationslaby- 
rinthosen)     Miinch.  med.  Woch.  62:  1269-70,  Sept.  14,  1915 

The  writer  emphasizes  a  certain  symptom  that  he  found  among  fifty  cases  of 
auditory  injuries  caused  by  detonations,  which  was  hitherto  practically  unknown. 
In  each  case  of  labyrinthine  shock,  sensory  disturbances  of  the  external  ear  could 
be  proven,  but  pure  affections  of  the  auditory  apparatus  were  never  demonstra- 
able.  An  extreme  sensibility  of  the  external  meatus  to  heat  and  cold  was  ap- 
parent. The  disturbances  of  sensibility  varied  according  to  the  injury  done. 
In  the  most  severe  cases  there  was  complete  analgesia. 

The  sensory  disturbances  were  not  dependent  on  the  distribution  of  the  periph- 
eral nerves.  In  most  cases  they  involved  the  whole  external  ear  and  a  zone  of  a 
finger's  breadth  around  it.  The  writer  believes  that  to  classify  these  sensory 
disturbances  as  hysteria  would  be  incorrect  since  there  were  no  other  clinical 
symptoms.  Symptoms  relating  to  the  vestibular  canal  were  of  very  slight 
prominence.  Vertigo  was  present  but  soon  disappeared.  Spontaneous  nystag- 
mus never  occurred.  It  may  be  of  interest  to  note  tliat  collections  of  cerumen  in 
the  ear  and  chronic  otitis  media  offered  a  certain  protection  against  the  effects 
of  detonation.     The  treatment  of  these  cases  consisted  of  rest  in  bed  for  the  first 


48 

few  days.  As  internal  medication  twenty-five  drops  of  tincture  of  valerian 
were  given.  Bromides  were  never  used.  In  all  such  cases,  suitable  occupations 
and  reading  matter  should  be  provided.  The  nurses  should  talk  to  the  patients 
in  clear  and  loud  tones  so  that  they  may  not  realize  their  defects  of  hearing. 
Patients  with  a  bilateral  impairment  of  the  cochlea  nerve  should  be  taught  lip 
reading.     A  few  interesting  cases  are  described. 


Weygandt,  W.  Observations  on  War  Psychiatry  (Kriegs-psychia- 
trische  Beobachtungen)  Psych,  neurol.  Woch.,  Hamburg,  Dec. 
II,  1915,  p.  215-16 

The  writer  has  observed  that  frequently  men  who  were  absolutely  healthy 
before  the  war,  and  some  who  had  had  symptoms  of  epilepsy  from  which  they 
had  apparently  recovered,  during  the  war  developed  hysterical  disturbances 
showing  epileptiform  symptoms. 

The  prognosis  in  cases  following  shock  or  exhaustion  is  very  favorable  so  that 
such  cases  need  not  be  considered  unfit  for  further  service,  especially  as  there  is 
such  a  great  need  for  recruits.  When  the  question  of  indemnity  arises  it  is  dif- 
ficult to  state  definitely,  in  such  cases  of  psychic  disturbance,  that  shock  and 
fatigue  are  the  only  causes  of  the  condition,  but  we  must  admit  that  war  experi- 
ences are  direct  causes  of  the  disease  in  individuals  with  a  luetic  taint,  in  manic 
depressives  and  in  cases  of  dementia  praecox. 

In  cases  of  so-called  "mobilization  psychosis",  particularly  of  the  catatonic  or 
paranoid  form,  a  latent  pre-existing  psychosis  must  frequently  be  assumed. 


Nonne,  Max.  The  Therapeutic  Use  of  Hypnosis  for  Cases  of  War 
Hysteria  (Zur  therapeutischen  Verwendung  der  Hypnose  bei 
Fallen  von  Kriegshysterie)  Med.  Klin.,  Berlin,  11:1391-96, 
Dec.  19,  1915 

The  writer  has  come  to  the  conclusion,  through  his  observations,  that  hysteria 
is  the  most  frequent  of  all  war  neuroses.  After  a  very  clear  and  comprehensive 
definition  of  hysteria  according  to  his  conception  of  the  term,  he  discusses  diag- 
nosis. The  first  point  emphasized  is  that  the  clinical  picture  and  course  of  the 
case  prove  absolutely  the  presence  of  a  purely  functional  disturbance;  whether  in 
the  genesis  of  the  clinical  picture  mechanical,  psychogenic  or  ideogenic  factors 
were  wholly  or  partly  active  or  entirely  absent  is  of  no  consequence  in  the  prac- 
tical diagnosis.  To  speak  of  cramp  neurosis,  akinesia,  dyskinesia  amnestica, 
fright  neurosis,  anxiety  neurosis,  cardio-vascular  symptom  complex,  etc.,  has 
no  point;  this  giving  to  certain  clinical  pictures  names  suggesting  the  possibility 
of  incurability  is  to  be  strictly  avoided. 

Nonne  found  151  neuroses  among  352  nervous  cases  that  came  under  his  care. 
Yet  the  proportion  of  such  cases  is  comparatively  small  when  one  realizes  that,  in 

making  the  rounds  of  the  reserve  hospitals  of  the Army  Corps,  among  600 

patients  there  were  only  ten  cases  of  war  neurosis.  The  writer  believes  that  a 
wrong  impression  as  to  this  proportion  has  been  spread  abroad  through  incorrect 
diagnoses.  He  describes  in  detail  several  cases  labeDed  as  organic  in  which  the 
predominant  symptoms  disappeared  after  a  few  hj^^notic  treatments,  and  ad- 
mits that  such  faulty  diagnoses  are  easily  made  in  cases  in  which  hysterical 
paralysis  is  associated  with  vasomotor  disturbances.  It  is  surprising  to  note 
the  disappearance  of  the  chief  symptoms  as  soon  as  the  functional  vasomotor 
disturbances  are  removed. 

Hysterical  disturbances  were  usually  monosymptomatic.  The  majority  of 
cases  had  never  shown  any  previous  signs  of  nervous  disturbance  or  of  a  neuro- 


49 

pathic  condition.     An  initial  state  of  unconsciousness  was  usual,  but  some  cases 
showed  no  disturbance  of  consciousness  at  any  time. 

The  writer's  observations  led  him  to  the  conclusion  that  in  most  cases  no  cure 
is  possible.  Sometimes  there  is  a  temporary  cessation  of  symptoms,  but  the  cure 
is  rarely  lasting  or  complete.  Curative  measures  employed  were  hydrotherapy, 
electrotherapy,  massage,  gymnastics,  and  mental  suggestion.  Hj'pnotism  has 
rarely  been  used,  for  there  is  a  marked  prejudice  on  the  part  of  the  medical  pro- 
fession against  its  employment  as  a  therapeutic  method.  The  author  makes  a 
strong  plea  for  its  use,  not  only  in  helping  the  patient  to  recover  from  his  dis- 
abling symptoms,  but  also  in  clarifying  the  diagnoses  of  doubtful  cases.  In  the 
sixty-three  cases  treated  by  him,  the  predominating  symptoms  were  as  follows: 

Abasia  astasia 14 

Superior  monoplegia 11 

Inferior  paraplegia 5 

Hemiplegia .' 3 

Mutism 5 

General  tremors 12 

Isolated  muscle  contractures 6 

Isolated  sensory  disturbances 1 

Isolated  tics 4 

Isolated  respiratory  spasms 2 

Of  these  sixty-three  cases,  fifty-one  were  cured,  or  rather  freed  of  their  symp- 
toms. One  case  out  of  each  of  the  above  groups  is  described  in  detail.  One 
quick  spontaneous  cure,  and  this  only  a  partial  one,  occurred  in  the  total  num- 
ber of  cases.  Five  patients  were  cured  by  suggestion  without  inducing  hyp- 
notic sleep,  and  twenty-eight  quick  cures  followed  the  use  of  hj-pnotism.  In 
twenty-three  cases  gradual  cures  were  brought  about  through  employing  hj'p- 
nosis.  In  closing,  Nonne  summarizes  the  etiological  factors  cooperating  in  the 
production  of  the  symptom  complex  of  hysteria.  Among  the  least  important 
are  neuropathic  heredity  and  diathesis.  Hypnosis  was  used  with  equal  success 
for  such  cases  and  for  patients  who  had  no  such  abnormality.  The  various 
classes  of  society  and  city  and  country  dwellers  showed  about  the  same  degree  of 
responsiveness  to  hj^pnotic  treatment. 

Lowy,  Max.  Neurological  and  Psychiatrical  Observations  on  the  War 
(Neurologische  und  psychiatrische  Mitteilungen  aus  dem 
Kriege)     Monat.  fiir  Psych,  u.  Neurol.,  Berlin,  37:  380,  1915 

With  the  exception  of  a  few  cases  of  intercostal  neuralgia,  trigeminal  neural- 
gia, herpes  zoster,  tetanus  following  dysentery  and  a  larger  number  of  cases  of 
eschias,  neurological  and  psychiatrical  disturbances  in  the  writer's  regiment  were 
rare.  This  regiment  belonged  to  the  "Landsturm"  and  was  composed  mostly  of 
men  between  the  ages  of  thirty-two  and  thirty-eight.  Light  beer  was  used  on 
the  average  of  from  three  to  four  pint-glasses  a  day.  This  amount  was  increased, 
however,  on  Sundays  and  holidays.  Whiskey  and  wine  were  rarely  used.  Men 
such  as  saloon-keepers,  waiters,  cooks,  etc.,  with  an  alcoholic  predisposition,  de- 
veloped cases  of  alcoholism. 

The  majority  of  psychoses  present  were  depression,  manic-depression,  and 
compulsive  ideas  on  a  depressive  and  psychasthenic  basis,  hypochondria,  de- 
mentia precox  and  epilepsy.  Attempts  at  suicide  were  rare.  iVll  those  with 
manifest  psychoses  had  been  excluded  at  the  time  of  the  physical  examination 
for  recruits,  therefore  the  number  of  cases  occuring  later  was  smaller  than  had 
been  expected. 

Since  war  is  like  prison  in  as  much  as  it  causes  a  total  change  of  the  conditions 
of  life,  one  might  expect  to  find  clinical  pictures  resembling  prison  psychoses. 


50 

However,  only  two  such  cases  occurred,  one  with  Ganger's  syndrome,  and  the 
other  with  paranoid  phantasy  symptoms  accompanied  by  hallucinations,  but 
with  no  loss  of  orientation. 

It  is  also  remarkable  that  among  1,000  soldiers  who  habitually  used  alcohol  in 
moderate  and  sometimes  larger  quantities  there  was  not  a  single  case  of  delirium 
tremens  after  several  weeks  of  total  abstinence  in  spite  of  the  presence  of  pre- 
disposing factors  such  as  gastro-intestinal  disturbances,  fever,  pneumonia, 
pleurisy,  etc.  Fresh  air  and  vigorous  exercise  seemed  to  offset  somewhat  the 
effects  of  predisposition.  In  one  case  the  use  of  alcohol  after  long  abstinence 
caused  a  pathological  intoxication. 

The  effects  of  heavy  shell-fire  are  next  in  importance  to  alcohol  as  an  etiological 
factor  in  psychiatric  cases.  Diarrhea  and  an  increase  in  dysentery  during  heavy 
shell-fire  was  frequently  observed.  Paresthesia  and  weakness  in  the  legs  often 
remained  days  after  the  cannonade  had  ceased.  Some  paresthetics  showed 
symptoms  of  symmetrical  hysteriform  analgesia  of  the  hands  and  feet,  most  fre- 
quently of  the  glove  and  stocking  type.  One  case  complained  of  poor  eyesight, 
and  one  showed  a  limitation  in  the  field  of  vision.  There  was  also  one  instance 
of  traumatic  neurosis  with  a  suggestion  of  verbigeration.  Cases  of  epilepsy 
during  the  march  or  in  the  fighting  line  were  rare. 


Meyer,  S.     War  Hysteria  (Kriegshysterie)    Deutsche  med.  Woch., 
Berlin,  42:  69-71,  Jan.  20,  1916 

The  clinical  picture  of  hysteria  changes  with  periods  of  time  and  with  man. 
It  reflects  like  a  mirror  phases  of  the  mental  states  of  man, — the  races,  classes, 
sexes,  and  different  degrees  and  kinds  of  education.  Hysteria  always  follows  in 
the  wake  of  great  movements,  therefore  it  is  to  be  expected  that  we  should  find 
it  now  accompanying  the  world  war. 

A  traditional  theory  has  existed  that  hysterical  symptoms  can  always  be  traced 
back  to  suggestion  or  auto-suggestion;  that  hysteria  is  really  imaginary.  The 
war  has  proved  conclusively  that  the  cause  of  hysteric  states  must  be  more  than 
mere  suggestion;  that  the  patient  must  have  had  an  actual,  disturbing  experi- 
ence to  develop  such  symptoms.  The  forms  in  which  hysteria  appears  are 
strongly  influenced  by  the  war.  For  instance,  hysterical  paralyses  are  very 
rare  among  males  in  times  of  peace,  but  in  wartime  they  are  numerous,  and  were 
invariably,  in  the  author's  experience,  sequelae  of  shell  explosions  or  of  injuries 
from  ■  bullets,  resulting  in  inability  to  use  the  limbs.  Contractures  are  often 
found  and  sometimes  a  combination  of  contracture  and  hysterical  paralysis. 

Prognosis  in  cases  of  hysterical  paralysis  following  shock  is  usually  favorable, 
but  paraplegias  resulting  from  bullet  wounds  are  apt  to  resist  treatment  rather 
stubbornly.  The  writer  condemns  strongly  the  suggestion  theory  of  the  origin 
of  hysteria  in  treating  patients.  He  advocates  assuring  cases  that  their  organs 
are  intact  and  that  they  will  certainly  recover  the  use  of  them,  but  he  denies  that 
they  can  be  "talked  out  of"  their  disease  any  more  than  that  they  have  been 
"talked  mto  it." 

The  exciting  causes  of  war  hysteria  are  varied,  but  all  have  a  common  ele- 
ment— the  affective  factor  which  is  the  sine  quo  non  of  the  production  of  the 
disease.  On  the  other  hand,  in  the  hysteria  of  everyday  life,  we  have  to  deal 
with  a  continuation  and  intensification  of  symptoms  due  to  some  pathological 
organic  condition. 

_  Treatment  is  not  easy,  but  is  invariably  successful  if  the  patient  can  be  con- 
vinced that  he  is  improving. 

Such  cases  should  never  be  returned  to  the  ranks,  as  relapses  are  almost 
inevitable. 


51 

Schultz,  J.  H.,  and  Meyer,  Robert.  On  the  Clinical  Analysis  of  the 
Effect  of  Shell-shock  (Ziir  klinischen  Analyse  der  Granatschock- 
wirkung)    Med.  Klin.,  Berlin,  12:  230-33,  Feb.  27,  1916 

The  term  "shell-shock"  is  often  applied  to  the  diagnosis  of  cases  where  the 
symptoms  are  not  all  recognized.  It  is  used  in  about  the  same  way  that  "trau- 
matic neurosis"  is  used  in  times  of  peace.  "Shell-shocked"  patients  are  those 
who  have  been  in  close  proximity  to  an  exploding  shell,  but  who  have  not  re- 
ceived any  visible  injuries.  They  may  complain  of  headache,  auditory  and 
equilibratory  disturbances,  insomnia,  changes  of  personality,  irritative  motor 
symptoms  and  tremors.  All  these  complaints  must  be  carefully  considered,  and 
close  cooperation  of  neurologist  and  otologist  is  advised.  The  Barany  testis 
indispensable.  The  writers  have  had  their  patients  examined  by  an  otologist 
first.  He  subclassified  them  into  (a)  cases  with  traumatic  rupture  of  ear  drum, 
and  (b)  those  with  the  otoscopical  picture  of  a  normal  drum.  Both  groups  had 
an  impairment  of  hearing  in  one  or  both  ears. 

The  histories  of  patients  were  recorded  as  completely  as  possible.  The  Barany 
test  was  finally  given  but,  since  no  revolving  chairs  were  obtainable,  the  observa- 
tions were  limited  to  the  phenomena  occurring  spontaneously  or  after  caloric 
stimulation. 

Several  cases  from  the  above  mentioned  groups  are  described.  To  illustrate 
the  method  of  examination,  a  single  tj^ical  case  wiU  sufiice.  A  certain  soldier 
came  under  observation  three  days  after  a  shell  had  exploded  directly  in  front  of 
him.  He  claimed  to  have  been  unconscious  for  fifteen  minutes,  and,  from  that\ 
time  on,  to  have  suffered  from  vertigo,  impairment  of  hearing  and  headache, 
especially  over  the  eyes  and  in  the  occipital  region.  There  had  been'no  vomiting 
however.  Otoscopy  showed  both  drums  unaffected,  with  normal  light  reflex. 
However  the  power  of  hearing  was  diminished  in  both  ears.  Family  history  was 
negative.  The  patient  had  taken  part  in  the  campaign  from  the[  beginning  and 
had  had  dysentery.  He  now  complained  of  "being  easily  startled"  and  of  dis- 
turbed sleep.  Examination  showed  sluggishness  of  pupillary'  reflexes  to  aU  stim- 
uli, mild  tremors  of  hands  and  tongue,  and  slightly  increased  reflexes. 

The  writers  draw  the  following  conclusions: 

Psychopathic  individuals  react  upon  a  psychophysical  injury  with  various 
symptoms  which  are  not  to  be  explained  by  the  nature  of  the  injury  but  by  the 
mode  of  reaction  of  the  individual  case.  It  is  for  this  reason  that  predisposed 
individuals  will  invariably,  in  case  of  shell-shock,  show  the  same  type  of  psycho- 
pathic symptoms  that  would  be  likely  to  arise  under  other  conditions  of  strain, 
A  few  cases  are  described  to  show  that  prognosis  in  non-predisposed  individuals, 
even  in  cases  of  severe  labyrinthic  disturbance,  is  much  better  than  that  in  pre- 
disposed persons. 

As  forms  of  treatment  the  authors  suggest  isolation,  hypnosis,  psychotherapy, 
catheterization  and  massage  in  accordance  with  individual  requirements. 


ITALIAN  LITERATURE 

Periodicals  Abstracted 
Chirurgia  degli  Organi  di  Movimento,  Bologna 
Giornale  di  Medicina  Militare,  Rome 
Policlinico,  Rome 
Riforma  Medica,  Naples 

Rivista  di  Patologia  Nervose  e  Mentale,  Florence 
Rivista  Italiana  di  Nem-opatologia,  Psychiatria  ed  Elettroterapia,  Catania 


ITALIAN  LITERATURE 

Mingazzini,  G.  Syndromes  of  Organic  Nervous  Lesions  following 
Shots  through  the  Brain  (Sindromi  nervose  organiche  consecu- 
tive a  lesioni  da  poviettli  del  cervello)  Policlinico,  Rome,  23: 
409-28,  Dec.  1916 

The  writer,  as  director  of  the  cUnic  for  nervous  diseases  at  Rome  has  had  ample 
opportunity  to  study  cases  of  bullet  shot  through  the  brain.  He  describes  in 
detail  seven  cases,  which  may  be  summarized  as  follows: 

1.  Penetrating  shot  through  the  left  parietal  bone,  corresponding  to  the 
Rolandic  area,  resulted  in  glosso-facio-brachial  paresis  on  the  right  side.  The 
accompanying  symptoms  are  hypesthesia,  stereognosis  and  pain  and  heaviness  in 
the  region  of  the  skuU  lesion.     A  secondary  operation  brought  great  relief. 

2.  Tangential  shot  through  the  left  parietal  bone,  causing  lesion  of  the  superior 
part  of  the  Rolandic  area  resulted  in  spastic  hemiplegia  with  atrophy  of  the  right 
hand  and  foot,  muscular  epileptiform  spasms  of  the  Jacksonian  type  on  the 
same  side,  and  marked  motor  abasia  and  hypesthesia,  especially  pronounced  in 
the  arm.  An  operation  cleared  up  these  symptoms,  leaving  only  hemi-hypesthe- 
sia. 

3.  Penetrating  shot  through  the  antero-medial  part  of  the  right  parietal  bone, 
causing  compression  of  the  middle  third  of  the  paracentral  lying  underneath, 
resulted  in  severe  left  hypesthesia  and  hemiplegia.  When  the  bone  splinters  had 
been  removed,  a  crural  monoparesis  still  remained,  together  with  a  more  circum- 
scribed hypesthesia. 

4.  Penetrating  shot  through  the  left  parietal  bone,  injuring  the  underlying 
cerebral  tissues,  resulted  in  severe  dysarthria,  spastic  paralysis  of  right  side, 
Jacksonian  epileptic  fits  and  right  hemi-hypesthesia.  An  operation  did  away  with 
all  symptoms  but  did  not  affect  the  sensory  disorders. 

5.  Penetrating  shot  through  the  left  parietal  bone,  causing  lesion  of  the  Rolan- 
dic area,  was  followed  by  complete  motor  aphasia,  right  hemiplegia  and  hypes- 
thesia. Operation  removed  the  aphasia  and  somewhat  lessened  the  paralysis 
but  did  not  alter  the  sensory  disorders. 

6.  Serious  injury  to  the  right  parietal  bone  caused  abscess  in  the  Rolandic 
area.  When  the  abscess  was  healed,  the  following  syndrome  remained:  spastic 
paralysis  of  the  extremities  on  the  left  side,  with  atrophy  more  marked  in  the 
upper,  Jacksonian  convulsions  in  these  same  limbs,  hypesthesia  and  petit  mal 
seizures. 

7.  Shot  through  the  postero-lateral  region  of  the  left  frontal  bone  with  com- 
pression of  the  centers  of  Broca  and  Rolando  resulted  in  motor  aphasia  and  right 
hemiparesis.  An  operation  did  away  with  these  symptoms  but  a  marked  as- 
thenia in  the  extremities  of  the  right  side  and  a  severe  dysarthria  appeared. 
From  these  observations  the  writer  draws  the  following  conclusions: 

1.  Broca's  region  contains  the  speech  centers  and  so  influences  directly  articu- 
lation. A  lesion  of  this  area  may  therefore  give  rise  to  motor  aphasia  and  some- 
times to  dysarthria. 

2.  Marburg  and  Ranzi's  statements,  that  bullet  injuries  of  the  brain  result  at 
first  in  a  flaccid  paralysis  which  only  rarely  tends  to  become  spastic,  should  be 
modified.  The  writer  has  observed  many  cases  with  persistent  spastic  paralysis 
associated  with  contractures. 

3.  Motor  and  sensory  areas  must  be  well  separated,  the  latter  extending  in  a 
posterior  direction  much  farther  then  the  former.  The  writer  believes  this,  since 
in  most  cases  operations  cleared  up  the  motor  disturbances  but  did  not  affect 
the  sensory  disturbances. 

55 


56 

Sandro,  D.  de.  Functional  Mutism  from  a  Bomb  Explosion  and 
Hysterical  Mutism;  their  Cure  by  Etherization  (II  mutismo  fun- 
zionale  da  scoppio  di  granata  e  quello  degli  isterici.  Loro  cura 
con  I'eterizzazione)  Riv.  patol.  nerv.  e  ment.,  Florence,  22 :  9, 
Jan.  1917 

A  record  of  two  cases,  in  a  soldier  aged  25  and  a  woman  aged  35,  in  whom  com- 
plete cure  of  their  mutism  took  place  after  three  or  four  minutes'  inhalation  of 
ether.  The  success  of  the  treatment  is  attributed  to  the  irritation  of  the  res- 
piratory tract  in  general  and  of  the  larynx  in  particular. — J.  D.  RoUeston,  Rev. 
of  neurology  and  psychiatry  15:  331,  Aug.  Sept.  1917. 

Redard,  Paolo.  Inability  to  Straighten  the  Spine  as  Effect  of  War 
Traumatism.  Chir.  degli  organi  di  movimento,  Bologna,  i: 
257-67,  May  1917.     lUus. 

Redard  gives  photographs  of  men  who  are  unable  to  stand  up  straight,  the 
attitude  resembling  that  of  one  trying  to  touch  the  floor  with  his  finger  tips. 
One  illustration  shows  twelve  men  with  this  form  of  contracture.  The  mild 
cases,  wdth  signs  of  hysteria,  recover  without  much  being  done,  but  the  medium 
cases  require  systematic  treatment,  and  the  grave  cases  with  organic  lesions  in 
the  spine  and  emaciation  are  usually  rebellious  to  treatment.  Psychotherapy 
and  contrasuggestion  are  useful  aids  to  the  usual  physical  therapy.  Men  with 
the  mild  forms  do  best  when  sent  home,  and  in  any  event  should  be  kept  apart 
from  others  with  the  same  trouble.  Attempts  to  straighten  the  spine  should 
be  made  very  gently.  Forcible  correction  in  psychoneuroses  may  induce  de- 
plorable aggravation.  As  the  trouble  is  almost  invariably  curable  sooner  or 
later,  the  question  of  discharge  from  the  army  on  account  of  disability  should 
not  be  even  suggested.— J.  A.  M.  A.  70:  350,  Feb.  2,  1918. 

SeppiUi,  G.  Mental  Disturbances  in  Soldiers  in  Relation  to  War  (I 
disturbi  mentali  nei  militari  in  rapporto  alia  guerra)  Riv.  ital. 
neuropatol.,  psichiatr.  ed  elettroter,  Catania,  10:  105-14,  May 
1917.    References 

Although  there  is  no  special  war  psychosis,  war  favours  the  development  of 
some  psychopathic  states  rather  than  others,  especially  those  in  which  the 
emotional  factor  and  physical  factor  constitute  an  important  etiological  element. 

Among  260  soldiers  admitted  to  the  asylum  at  Brescia  the  majority  presented 
confusional  syndromes.  Other  psychoses  were  less  frequent.  Neurasthenia 
and  hysterical  syndromes  were  seen,  especially  those  showing  ambulatory  de- 
terminism and  other  atypical  forms. — ^J.  D.  Rolleston,  Rev.  of  neurology  and 
psychiatry  15:  337,  Aug.-Sept.  1917. 

Agostini,  Cesare.  Use  of  Epileptics  in  the  War  Zone  (Sulla  utilizza- 
zione  degli  epilettici  in  zona  di  guerra)  G.  med.  mil.,  Rome,  67: 
24-33.  Jan.  31,  1918 

Agostini  seriously  discusses  this  subject.  The  likelihood  of  seizures  at  inoppor- 
tune moments  would  ordinarily  eliminate  the  epileptic  from  any  sort  of  military 
service.  Nevertheless  "epilepsy"  is  a  very  elastic  term,  comprising  numerous 
conditions  in  which  major  crises  do  not  occur,  as  well  as  states  which,  while 
attended  with  convulsions,  belong  not  really  under  epilepsy  but  under  psychas- 
thenia.  It  is  the  subject  who  suffers  only  with  the  infrequent  mild  or  abortive 
crisis  or  symptomatic  paroxysm  who  could  be  utilized  for  military  work.  It  is 
admitted  that  war  has  caused  or  awakened  only  a  very  small  number  of  cases  of 


57 

true  epilepsy.  Many  subjects  of  trifling  epilepsy  are  interned  in  insane  asylums 
and  prisons  and  some  of  them  have  learned  trades  and  become  skilled  workmen. 
Such  men  are  also  found  in  civil  life,  supporting  themselves  and  but  little  in- 
convenienced by  their  infrequent,  mild  seizures.  Of  142  alleged  epileptics 
referred  to  the  author's  insane  asylum,  not  over  a  third  proved  to  be  true  epilep- 
tics. The  same  overwhelming  proportion  of  false  epileptics  occur  in  other 
statistics.  Apparently  the  skilled  artisans  among  these  subjects  are  those  most 
needed.— Med.  rec.  93:  644,  April  13,  1918. 

Gatti,  L.    Paralysis  from  Shell  Air  Shock.    Rif.  med.,  Naples,  34: 102, 
Feb.  9,  1918 

Gatti  reports  a  case  of  extremely  acute  paralysis  with  atrophy  following 
close  on  explosion  of  a  large  bomb  without  actual  contact.  The  tetraplegia  was 
of  the  type  of  anterior  poliomyelitis,  and  Gatti  assumes  that  the  anterior  portion 
of  the  spinal  cord  had  been  injured  by  the  air  contusion.  He  knows  of  only  one 
similar  case  on  record.  The  paralysis  and  the  atrophy  gradually  invaded  all 
the  musculature  except  in  the  head  and  neck,  but  there  were  no  sensory  dis- 
turbances and  the  sphincters  behaved  normally.  Instances  of  traumatic  anterior 
poliomyelitis  are  on  record.  Some  injury  of  the  blood  vessels  in  the  bulbar 
region  is  evidentlv  responsible  for  the  whole  set  of  symptoms. — J.  A.  M.  A.  70 : 
1267,  April  27, 19i8. 


LITERATURE   OF  THE  NETHERLANDS 

Periodicai^  Abstracted 
Nederlandsch  Tijdschrift  voor  Geneeskunde,  Amsterdam 


LITERATURE   OF  THE  NETHERLANDS 

Van  der  Hoeven,  H.    Psychoses  in  Camp.    Nederlandsch  tijdschrift 
voor  geneeskunde,  Amsterdam,  i :  158,  Jan.  19,  1918 

Van  der  Hoeven  relates  that  complete  anesthesia  of  both  halves  of  the  body 
was  found  almost  constantly  in  the  several  hundred  soldiers  that  have  passed 
through  his  service  for  nervous  and  mental  disease.  He  foimd  further  that  a 
large  percentage  of  the  men  could  have  the  cornea  struck  with  the  handle  of  a 
percussion  hammer  without  the  least  trace  of  pain.  There  was  lacrimation  but 
no  pain.  Restriction  of  the  visual  field  was  common,  and  urticaria  was  easily 
induced  by  stroking  the  skin.  He  comments  on  the  difficulty  in  the  military 
environment  of  examining  men  with  psychopathies.  The  commander  assumes 
simulation  whenever  a  man  with  normal  temperature  complains  of  symptoms, 
and  it  is  a  fact  that  now  all  the  manifestations  of  disease  are  more  or  less  influ- 
enced in  the  soldier  by  his  distaste  for  military  service  and  his  longing  to  go 
home.  Entirely  opposite  to  the  e3q)eriences  in  civihan  circles,  the  mobilized 
Netherlands  soldier  more  or  less  unconsciously  strives  to  make  the  most  impres- 
sive presentation  of  his  symptoms.  With  all  other  forms  of  disability,  the  classi- 
fication of  the  men  as  fitted  for  full  duty,  light  duty,  and  capable  only  of  man- 
ual work,  has  proved  beneficial,  but  not  so  with  the  psychopathies. — J.  A.  M.  A. 
70:  1046,  April  6, 19l8. 


61 


RUSSIAN   LITERATURE 

Periodicals  Abstracted 
Russkiy  Vrach,  Petrograd 


RUSSIAN   LITERATURE 

Soukhanofif,  S.  A.    War  Psychoneuroses.    Russkiy  vrach,  v.  14,  1915 

Soukhanofif  does  not  admit  that  the  war  generates  special  psychoses  which  might 
be  referred  to  a  new  definite  group  of  mental  derangement.  Only  the  external 
manifestations  of  the  usual  psychoses  may  be  modified;  the  essential,  fundamen- 
tal symptoms  and  signs  remain  unchanged.  The  most  common  psychoneurosis, 
the  traumatic,  appears  in  two  forms :  the  commotional  type,  due  to  air  concussion 
of  the  central  nervous  system,  and  the  psychogenous  hysterical  type,  caused  by 
the  emotional  shock.  Then  there  also  occur  combined  forms  in  which  the  symp- 
toms of  both  these  types  are  found.  In  some  cases,  the  psychogenous  hysterical 
phenomena  complicate  the  clinical  picture  of  an  already  existing  neurosis,  such 
as  psychasthenia  and  epilepsy.  Finally,  it  must  be  admitted  that  air  concussion 
may  cause  anatomic  changes  in  the  viscera  and  the  central  nervous  system,  even 
without  external  lesions. — J.  A.  M.  A.  65:  1150,  Sept.  25,  1915. 


65 


SCANDINAVIAN  LITERATURE 

Febiodicai^  Abstracted 
Hygiea,  Stockholm 


SCANDINAVIAN  LITERATURE 

Nordlund,  H.   To  Detect  Simulation  of  Deafness.    Hygiea,  Stockholm, 
79: 1361,  Dec.  31,  1917 

The  long  list  of  measures  that  have  been  proposed  to  detect  malingering  in 
regard  to  the  hearing  shows  that  none  of  them  is  absolutely  reliable.  Nordlund 
describes  fourteen  methods  based  on  sp>eech;  eleven  tuning  fork  or  similar  meth- 
ods, and  seven  methods  for  detecting  bilateral  deafness.  Few  attempt  to 
simulate  absolute  bilateral  deafness;  if  it  is  attempted,  the  Gowseef  method  or 
the  Kindlmann  method  is  instructive.  With  the  former,  the  man's  back  is 
brushed  with  a  brush  or  the  hand  or  both.  Then  the  investigator  uses  only  one 
on  the  subject  and  the  other  on  his  own  coat,  brushing  his  own  coat  with  the 
brush  or  hand  while  the  subject's  coat  is  brushed  with  the  other.  The  sound  and 
the  touch  combine  so  that  the  normally  hearing  are  unable  to  tell  whether  the 
hand  or  the  brush  is  being  used  on  their  own  backs.  The  deaf  person,  not  hearing 
the  sound  on  the  other  i>erson,  is  able  to  tell  by  the  sensation  on  his  own  back 
which  is  being  used.  Unilateral  deafness  is  tested  best,  perhaps,  with  the  Lom- 
bard-Barany  method,  that  is,  the  use  of  an  apparatus  that  produces  a  noise 
intermittently  while  the  subject  is  reading  aloud  in  his  ordinary  voice.  Uncon- 
sciously he  raises  his  voice  and  loses  control  of  it  when  he  hears  the  noise  of 
the  automatic  drum.  It  may  be  necessary  to  apply  a  number  of  the  tests  to 
detect  the  simulation;  if  all  give  concordant  results,  they  may  be  accepted  as 
conclusive.— J.  A.  M.  A.  70:  968,  March  30,  1918. 


69 


LITERATURE   OF  THE  UNITED   STATES 

Periodicals  Abstracted 
American  Journal  of  Public  Health,  Boston 
American  Medicine,  New  York  City 
Boston  Medical  and  Surgical  Journal 
Journal  of  the  American  Medical  Association,  Chicago 
Medical  Record,  New  York  City 
Mental  Hygiene,  New  York  City 
Military  Surgeon,  Washington 
New  York  Medical  Journal 
New  York  State  Hospital  Quarterly,  Utica 
Proceedings  of  the  Boston  Society  of  Psychiatry  and  Neurology 
Proceedings  of  the  New  York  Neurological  Society 
Proceedings  of  the  United  States  National  Academy  of  Sciences, 
Washington 


LITERATURE   OF   THE   UNITED    STATES 

Auer,  E.  Murray.    Some  of  the  Nervous  and  Mental  Conditions  Arising 
in  the  Present  War.    Mental  hygiene  i :  383-88,  July  19 17 

Auer  advocates  the  assigning  at  base  hospitals  of  huts  to  the  neuropsychiatric 
service  where  soldiers  suffering  from  functional  nervous  and  mental  conditions 
may  receive  treatment  in  the  way  of  rest,  isolation,  proper  food,  etc. 

The  great  change  for  the  soldier  usually  occurs  on  the  firing  line.  The  aver- 
age man  goes  into  training  directly  from  indoor  office  work  and  is  greatly  im- 
proved physically  and  morally  by  this  training  and  by  the  outdoor  life,  but  later 
the  fatigue  of  long  marches,  exposure,  worry,  the  monotony  of  the  trenches, 
morbid  fears,  horrible  sights,  all  tend  to  fan  to  a  flame  any  neuropathic  predis- 
position— and  careful  inquiry  into  individual  histories  has  almost  invariably 
shown  that  earlier  neurotic  manifestations  can  be  proved  in  cases  of  nervous 
breakdown.  Physically  these  individuals  are  of  the  average  masculine  type, 
often  exhibiting  stigmata  of  degeneration,  such  as  low  brow,  facial  asymmetry, 
adherent  lobules,  deviated  septum,  high  palate,  etc. 

Auer  cites  briefly  a  number  of  illustrations,  taken  from  his  observations  while 
on  hospital  duty  with  the  British  expeditionary  force,  of  the  numerous  and 
varied  manifestations  of  "shell  shock". 

"The  element  of  fear  or  anxiety  was  relatively  uncommon,  considering  the 
wealth  of  fear-producing  stimuli,  but  in  the  markedly  neuropathic  individuals 
one  encountered  a  feeling  of  incompetence,  a  fear  of  doing  something  wrong  and 
consequently  being  shot,  a  premonition  of  some  impending  danger,  a  fear  that 
something  might  arise  in  which  he  would  fail  or  of  going  to  sleep  lest  he  should 
not  awaken.     .     .     . 

"This  outline  is  offered  merely  as  a  brief  suggesstion  of  the  comprehensive 
possibihties  and  the  necessity  for  trained  neurologists  and  psychiatrists  in  the 
present  great  war.  Depressing  as  are  these  manifold  conditions,  it  is  with  intense 
pleasure  that  one  sees  the  usually  fortunate  outcome  of  proper  care  in  their  disap- 
pearance and  the  re-establishment  of  mental  equilibium.  ...  At  the  base 
hospital  one  can  fairly  well  employ  psychotherapy  in  the  form  of  absolute  quiet, 
isolation,  re-education  and  persuasion,  and  medicotherapy,  hydrotherapy  and 
lumbar  puncture  when  indicated.  I  cannot  insist  too  strongly  upon  the  value 
of  quiet,  rest  and  isolation  as  practiced  by  placing  screens  when  available  be- 
tween the  cots  in  the  early  control  of  these  cases.  .  .  .  Removed  from  the 
site  of  trauma,  the  noise,  and  din,  reassured  as  to  safety,  after  a  complete  rest 
of  varied  duration,  the  individual  is  almost  invariably  able  again  to  resume  his 
place  in  civil  life,  where  in  time  he  looks  back  upon  his  illness,  as  he  himself  not 
infrequently  will  say,  'as  a  dream,'  or  sometimes,  more  fortunately,  has  no 
recollection  of  his  experience." 

Farrar,  Clarence  B.    The  Problem  of  Mental  Disease  in  the  Canadian 
Army.  Mental  hygiene  i:  389-91,  July  1917 

Of  the  total  number  of  soldiers  invalided  to  Canada,  the  proportion  of  nervous 
and  mental  cases  has  been  fairly  constant  at  10  per  cent,  classified  as  follows: 

1.  Neurotic  reactions,  58  per  cent. 

2.  Mentiil  diseases  and  defect,  16  per  cent. 

3.  Head  injuries,  14  per  cent. 

4.  Epilepsy  and  epileptoid,  8  per  cent. 

5.  Organic  diseases  of  the  central  nervous  syst<-ni.  4  jxr  <<'iit. 


74 

These  figures  are  compiled  from  the  returns  of  medical  boards  which  examine 
the  men  to  determine  discharge  disability. 

Group  1  may  be  subdivided  as  follows:  (a)  Constitutional  neurotic  tempera- 
ment. More  or  less  permanent  condition  aggravated  during  service,  not  nec- 
essarily at  the  front,  (b)  Somatoneuroses.  Injuries  and  illness  whether  pre- 
existent  or  due  to  service,  upon  which  disproportionate  subjective  symptoms 
have  been  built,  and  wliich  often  long  survive  the  actual  physical  disability,  (c) 
Specific  war-reactions  developing  in  the  majority  of  cases  at  the  front  under  stress 
of  fighting.  Predisposition  is  of  course  very  often  demonstrable  in  these  cases  as 
well.  Most  typical  of  these  reactions  is  the  so-called  "shell-shock,"  although, 
to  be  sure,  this  condition  in  common  with  others  of  the  group  is  made  up  of 
symptoms  characteristic  of  the  neuroses  in  general.  From  the  military  records 
it  is  not  possible  to  differentiate  numerically  these  various  types,  but  the  third 
subgroup  far  outnumbers  the  others. 

Group  2  comprises:  (a)  Psychoses  of  familiar  types,  the  majority,  as  would  be 
expected,  being  dementia  praecox.  (b)  Primary  mental  defect,  (c)  Psycho- 
patliic  inferiority.  This  condition,  easily  unrecognized  in  routine  medical 
boards,  has  been  the  cause  of  many  obvious  difficulties.  The  class  includes 
many  of  the  inefficient  and  undesirable  soldiers,  whose  history  often  shows  that 
they  have  made  good  neither  in  civil  nor  military  life.  They  are  usually  the 
trouble  makers  in  the  convalescent  homes  and  furnish  a  considerable  number  of 
the  men  with  grievances  concerning  pension  claims  and  treatment  of  the  returned 
soldier  in  general. 

Group  3  is  made  up  mostly  of  cases  of  gunshot  or  shell  wounds  of  the  head, 
with  loss  of  bone.  Strictly  considered,  the  majority  of  these  cases  might  be 
omitted  from  the  categories  of  nervous  and  mental  diseases.  It  is  very  rare  for 
a  head  case  of  this  sort  to  present  symptoms  of  neurosis  or  psychosis.  Variable 
headache  and  dizziness  are  the  only  fairly  constant  symptoms. 

In  group  4  the  percentage  of  genuine  epilepsy  is  not  determinable  from  avail- 
able records.  Some  of  the  cases  with  epileptiform  convulsions  turn  out  to  be 
initial  paresis,  or  dementia  praecox,  or  a  neurosis. 

Group  5,  the  smallest  of  all,  is  made  up  chiefly  of  paresis  and  tabes,  with  rare 
diagnoses  of  brain  tumor,  multiple  sclerosis,  etc. 

The  program  of  differentiation  and  group  treatment  of  nervous  and  mental 
conditions  among  returned  soldiers  in  Canada  includes: 

1.  A  reception  hospital  for  war  neuroses  and  similar  conditions,  observation 
of  doubtful  states,  etc.  These  cases  are  received  at  the  Ontario  Military  Hos- 
pital at  Cobourg. 

2.  An  institution  for  the  severe  and  chronic  types  of  mental  disease.  Hitherto 
these  cases  have  as  a  rule  been  sent  to  the  provincial  hospitals  in  their  respective 
districts. 

3.  The  establishment  of  an  institution  or  colony  for  epileptics  is  under  con- 
sideration. 

4.  The  establishment  of  a  center  for  the  observation  and  treatment  of  syphili- 
tic conditions  is  also  contemplated.  In  most  of  the  cases  of  paresis  and  tabes 
there  is  a  pre-enlistment  history  of  infection,  but  the  evidence  on  the  records 
points' as  a  rule  to  the  development  of  the  disabling  symptoms  during  service. 
The  question  of  pensionability  in  many  cases  offers  considerable  difficulty.  The 
importance  of  attention  to  syphilitic  history  and  serological  and  neurological 
evidence  of  syphilis  at  examination  of  recruits  is  very  obvious. 

Hitherto  where  syphilitic  treatment  has  been  indicated  in  continuation  of  that 
begun  overseas,  this  has  as  a  rule  been  done  in  active  treatment  hospitals,  while 
the  later  cases,  such  as  paresis,  have  found  their  way  to  the  provincial  hospitals. 
An  initial  segregation  of  all  syphilitic  cases  among  returned  men  at  a  center 
where  all  the  indications  of  observation,  classification  and  treatment  could  be 
met  is  believed  to  be  desirable. 


75 

5.  Convalescent  homes.  These  were  the  first  institutions  established  in 
Canada  for  the  reception  of  disabled  soldiers  and  accommodate  all  types  of  con- 
valescents. While  there  is  but  one  special  institution  of  each  type  above  referred 
to,  the  convalescent  homes  are  scattered  throughout  the  Dominion  and  to  them 
cases  are  transferred  when  treatment  has  reached  a  late  stage  and  especially  if 
it  is  desirable  that  an  invalid  should  be  in  an  institution  in  his  home  district. 

The  war  reactions  outnumber  probably  all  other  types  of  nervous  disability 
combined  and  demand  proportionate  attention  in  management  and  treatment. 
At  the  special  institution  at  Cobourg  the  following  points  are  kept  in  mind: 

(a)  The  maintenance  of  military  discipline  and  individualized  control  is  found 
to  be  of  indispensable  and  first-rate  importance  in  dealing  with  these  cases. 

(b)  Hydro-and  electro-therapeutic  treatment  is  of  considerable  service  in 
many  cases. 

(c)  Occupation-therapy  with  suitable  variety  of  work  is  of  almost  universal 
importance. 

Treatment  of  a  higlily  specialized  sort  has  been  developed  under  the  auspices 
of  the  psychological  department  of  Toronto  University,  following  the  plan  of 
motor  training  applied  by  Dr.  Franz  at  the  Government  Hospital  in  Washington. 
This  method  is  found  useful  in  certain  cases  of  functional  paralysis,  incoordina- 
tion, affect-inhibitions,  tremors,  and  other  kinetic  disorders. 

In  the  general  policy  of  caring  for  the  war  neuroses  it  has  been  demonstrated 
over  and  over  again,  that  patients  while  under  treatment  should  be  shifted  as 
little  as  possible  from  one  institution  to  another.  It  is  also  as  a  rule  not  well  to 
have  the  patient  in  the  vicinity  of  his  home,  and  home  visits  are  certainly  con- 
traindicated  in  the  severer  neuroses.  The  conscious  will  and  purpose  to  get 
well  are  often  difficult  to  establish  and  all  opposing  factors  must  be  kept  in  mind. 

MacCurdy,  John  T.     War  Neuroses.     Psychiatric  bull.  2 :  243-354, 
July  1917 

Dr.  MacCurdy  defines  war  neuroses  as  "those  functional  nervous  conditions 
arising  in  soldiers  which  are  immediately  determined  by  modern  warfare  and 
have  a  symptomatology  whose  content  is  directly  related  to  war."  Two  t\pes 
of  war  neuroses  exist  and  may  be  classified  as  (1)  conditions  of  anxiety,  and  (2) 
conditions  of  simple  conversion  hysteria.  Case  liistories  illustrating  these  two 
types  are  given.  The  first  trial  the  recruit  usually  meets  is  the  exijcrience  of 
being  shelled  and  he  is  immediately  struck  with  fear.  The  sight  of  the  mangled 
remains  of  comrades  also  creates  horror  and  it  is  with  great  efi"ort  that  the  soldier 
is  able  to  check  his  feelings  and  grow  accustomed  to  these  sights.  ISlany  such 
individuals  do  not  fully  recover  from  this  state  of  mind  and  are  therefore  poorly 
adapted  to  a  soldier's  life.  They  are  quickly  fatigued  and  develop  disal)ling 
symptoms.  Fatigue  is  of  great  importance  in  the  devcloj)mcnt  of  a  neurosis  as 
it  is  the  almost  universal  occasion  of  the  dissatisfaction  witli  his  work  which  leads 
to  a  breaking  down  of  the  soldier's  adaptability  and  the  development  of  more 
permanent  symptoms.  The  conditions  producing  fatigue  are  l)oth  physical  and 
mental.  This  condition  is  characterized  by  a  feeling  of  tenseness,  a  restless  de- 
sire for  action  or  distraction,  irritability,  difficulty  in  concentration  and  a  tend- 
ency to  start  at  a  sudden  sound,  such  as  that  of  expUxUng  shells,  without  really 
being  afraid.  At  night  there  is  great  difficulty  in  falling  askvp  with  a  long  perit)d 
of  hypnagogic  hallucinations.  When  sleep  (loes  come,  it  is  troubled  by  dreams 
and  therefore  afforrls  no  real  rest.  When  this  condition  persists  for  some  time, 
fear  develops  and  then  horror  at  the  sights  of  carnage.  Kitlier  a  physical  ac- 
cident or  a  mental  shock  may  cause  the  final  comi)lete  breakdown.  The  stupor- 
ous states  that  follow  a  concussion  or  some  mental  trauma  may  be  characterized 
by  a  loss  of  consciousness  followed  by  a  period  during  which  consciousness  re- 
appears and  then  subsides  again.     While  conscious,  the  patieiil  is  extremely  con- 


76 

fused,  disoriented,  complains  of  severe  headache,  is  frequently  incontinent  or 
suffers  from  retention  and  may  have  to  be  catheterized.  Delirium,  too,  at  this 
time  is  a  usual  occurrence.  In  the  functional  type  of  stuporous  state,  the  patient 
lies  with  dilated  pupils,  in  a  cold  sweat,  with  shallow  breathing,  incapable  of  any 
voluntary  movement  and  often  trembling  violently.  When  voluntary  move- 
ment is  possible  he  is  dazed,  inactive,  confused  and  amnesic.  In  this  stage  of 
the  neurosis,  the  patient's  sleep  is  greatly  troubled  by  violent  nightmares  and 
becomes  something  to  be  dreaded.  Photophobia  may  be  a  frequent  occurrence 
in  the  acute  phases  of  the  neuroses.  ^Tremors  are  always  present,  and  sometimes 
ataxia.  Symptoms  suggestive  of  disturbances  of  the  thyroid  glands  are  very  fre- 
quent, but  usually  disappear  in  a  short  time.  The  eyes  protrude  slightly,  and  the 
upper  eyelid  may  lag  behind  the  eyeball  on  looking  down;  the  pulse  is  rapid,  there 
is  excessive  cold  sweating  and  sometimes  an  enlargement  of  the  thyroid  gland. 
Emotional  coldness  and  inability  to  express  affection  are  frequent.  These  symp- 
toms tend  to  subside  after  a  few  weeks,  but  may  last  months.  The  patient 
is  still  easily  fatigued  and  stiU  starts  at  sounds.  Complications  are  likely  to 
appear,  the  most  frequent  of  which  is  depression.  The  patient  is  dissatisfied 
first  with  himself  and  then  with  the  way  in  which  he  is  treated.  It  is  easy  to 
differentiate  between  malingering  and  anxiety  neuroses,  since  the  malingerer 
will  not  speak  frankly  about  his  terror  whereas  the  man  in  a  true  anxiety  state 
does  not  try  to  conceal  it. 

The  treatment  of  the  anxiety  states  depends  upon  the  individual  and  should  be 
psychologically  determined  so  that,  whatever  the  cause,  its  effect  may  be  re- 
moved. For  tliis  reason,  consistent  plans  of  treatment  should  be  followed  and 
patients  transferred  as  little  as  possible  from  one  hospital  to  another.  They 
should  be  placed  in  a  quiet  environment  and  yet  not  too  far  away  from  the  firing 
line  so  that  they  may  not  develop  an  idea  of  permanent  freedom  from  military 
duties.  The  first  step  in  treatment  should  be  absolute  rest,  usually  for  a  short 
time,  so  as  to  remove  the  fatigue  symptoms.  Sedatives  should  be  used  as  little 
as  possible,  preferably  only  on  the  first  night.  The  patient  must  then  be  told 
that  he  will  soon  recover  but  that  he  must  help  bring  this  about;  that  he  will  not 
be  asked  to  do  anything  disadvantageous  to  his  health  but  that,  since  liis  disease 
is  curable,  he  will  eventually  have  to  be  sent  back  to  the  line.  Everything  should 
be  made  as  quiet  and  pleasant  as  possible  for  him.  Occupation  in  some  form 
should  be  provided  in  every  case,  but  it  should  be  under  the  control  of  the  phy- 
sician who  should  watch  its  effects  on  each  patient.  It  is  essential  for  a  cure  that 
the  patient  get  some  insight  into  the  cause  of  his  neurosis  and  that  he  be  made  to 
understand  how  he  had  developed  a  tendency  to  tliink  of  liimself  rather  than  of 
the  need  of  the  army  and  the  country  and  so  became  a  victim  of  fear  and  horror. 
When  he  sees  that  it  was  purely  a  selfish  desire  to  avoid  responsibility  as  a  citi- 
zen he  will  try  to  control  his  symptoms.  In  a  short  time,  the  man  worth  while 
will  be  eager  to  help  in  the  struggle.  The  physician  must  always  sympathize 
with  the  patient  as  an  individual  but  must  never  relax  medical  discipline. 
Many  case  histories  are  given  to  illustrate  the  course  of  the  anxiety  states. 

Conversion  hysterias  are  more  frequent  than  the  pure  anxiety  states  but  they 
are  much  simpler  in  mechanism  than  the  latter.  They  are  defined  as  neuroses 
"in  which  there  is  an  alteration  or  dissociation  of  consciousness  regarding  some 
physical  function."  Fatigue  and  anxiety  are  important  factors  in  these  cases 
but  to  a  less  degree  than  in  pure  anxiety  states.  The  symptomatology  is  ex- 
tremely varied  and  consists  mostly  of  those  conditions  that  would  provide  relief 
from  active  service.  Mutism,  aphonia  and  deafness  are  most  frequent.  Motor 
disturbances  including  monoplegias  and  paraplegias  or  paresis  are  next  in  im- 
portance. Tics,  spasms,  contractures,  tremors  are  very  common.  Hyper- 
esthesias may  occur  alone  whereas  paresthesia  and  anesthesia  usually  accompany 
hysterical  symptoms.  Blindness,  amblyopia  and  disorders  of  smell  and  taste 
are  rare.     There  is  nearlv  alwavs  some  weariness  and  a  distinct  aversion  to 


77 

fighting.  The  wish  for  a  "bhghty  one",  or  some  form  of  physical  injury  or 
disease,  is  present  in  practically  every  case.  Occasionally  the  aversion  to  fight- 
ing is  the  direct  outcome  of  physical  accident  or  disease  that  removes  the  patient 
from  the  trenches,  creating  a  desire  not  to  return.  This  attitude  constitutes  the 
background  of  hysteria.  ^Vhen  organic  and  functional  disturbances  are  com- 
bined diagnosis  is  difficult.  The  functional  disturbances  may  overlap  the  other 
and  the  physician  may  believe  the  condition  to  be  non-organic.  In  such 
cases  a  final  diagnosis  may  be  made  only  after  treatment  on  purely  functional 
lines  has  been  successful  and  has  reduced  the  disability  to  its  organic  distribu- 
tion.    .     .     . 

"Quite  the  most  difficult  problem,  however,  is  to  differentiate  a  conversion 
hysteria  from  malingermg.  As  I  have  had  little  opportunity  to  see  cases  of 
malingering  as  thej'  are  presented  at  the  front,  I  am  unable  to  say  much  on 
this  topic  that  is  not  second-hand.  Some  workers  rely  largely  on  the  suggesti- 
bility of  the  hysterical  patient  as  a  diagnostic  criterion.  Occasionally  one  meets 
with  a  physician  who  goes  so  far  as  to  state  that  no  patient  who  is  not  hj'pno- 
tizable  has  a  true  hysteria,  and  therefore  must  be  malingering.  As  the  individual 
capacity  to  hypnotize  varies  greatly  from  man  to  man  tliis  is  probably  a  rather 
unsafe  rule.  Again,  if  one  relies  on  the  impression  wliich  the  personality  of  the 
patient  makes  on  the  physician,  error  is  apt  to  be  frequent.  The  true  malingerer 
is  usually,  if  not  always,  a  psychopath.  Again  it  may  require  a  rather  exhaustive 
study  to  determine  whether  the  symptoms  are  produced  on  the  basis  of  a  con- 
scious or  an  unconscious  wish,  wliich  is  essentiallj'  the  difference  in  etiology  be- 
tween malingering  and  hysteria.  Probably  the  safer  guide  is  the  liistory  of 
onset.  One  should  inquire,  therefore,  as  to  the  mental  attitude  of  the  patient 
before  the  symptoms  began.  In  a  true  hysterical  case  an  admission  is  apt  to  be 
made  as  to  the  breaking  down  of  adaptation  to  warfare  and  the  consequent  wish 
to  be  rid  of  it  all,  particularly  the  wish  for  an  mcapacitating  wound.  The  malin- 
gerer is  not  apt  to  reveal  the  history  because  the  symptom  represents  this  wish 
to  him  quite  consciously.  The  hysteric,  on  the  other  hand,  because  there  has 
been  an  unconscious  motivation,  does  not  see  the  connection  between  this  pre- 
vious desire  to  be  incapacitated  and  the  symptom  liis  malady  presents.  He  is, 
therefore,  more  apt  to  be  frank  in  the  matter.  In  another  respect  the  history 
may  be  of  importance,  I  imagine.  In  all  the  cases,  which  I  have  had  an  oppor- 
tunity of  examining,  whose  symptoms  arose  wliile  in  the  trenches,  there  was  a 
history  either  of  concussion  or  of  a  definite  precipitating  cause,  the  immediate 
result  of  which  was  some  disturbance  of  consciousness,  no  matter  how  slight. 
Frequently  it  amounted  to  no  more  than  the  patient's  being  dazed  for  a  few 
minutes  and  finding  himself  with  the  hysterical  symptom,  when  he  became  quite 
clear  again.  As  the  opinion  of  the  physician  on  this  matter  when  delivered  to  a 
court  martial  may  mean  life  or  death  for  the  soldier,  I  would  prefer  to  leave  this 
last  diagnostic  criterion  as  a  suggestion  until  such  time  as  further  experience  may 
show  whether  the  phenomenon  in  question  is  universal  or  not." 

Naturally  individuals  with  a  psychoneurotic  temperament  are  more  apt  to 
develop  symptoms  and,  when  these  are  removed,  to  develop  new  ones,  than  the 
more  normal  soldiers.  However,  symptoms  may  remain  for  a  long  time,  even 
in  the  latter  group,  unless  appropriate  treatment  is  given. 

Strict  discipline  has  often  been  successful  but  there  is  always  the  danger  that 
too  much  coercion  may  be  regarded  by  tlic  patient  as  unjust  and  therefore  a 
firmer  foundation  for  neurotic  symptoms  be  laid.  Treatment  based  on  sug- 
gestion, including  hypnotism  augmented  by  electricity,  has  been  more  suc- 
cessful than  disciplinary  treatment  but  many  objections  may  be  made  to  this 
combined  method.  It  is  of  doubtful  value  because  it  aims  at  the  removal  of 
symptoms  rather  than  of  causes.  The  patient,  himself,  cured  in  such  a  way, 
regards  the  treatment  as  a  miracle  and  fears  recurrence.  The  best  method  of 
treatment  for  the  conversion  hysterias  is  undoubtcfily  reeducation.     The  patient 


78 

should  be  told  the  nature  of  his  symptoms  and  that  he  must  help  to  regain  the 
lost  function.  At  this  point  suggestion  may  be  of  great  value.  It  is  also  of  im- 
portance that  the  physician  establish  a  friendly  relationship  with  the  patient 
and  encourage  him  to  speak  openly  of  his  fears  and  troubles. 

Many  men  are  invalided  from  the  trenches  with  heart  symptoms,  who  show 
no  signs  of  valvular  trouble.  This  has  been  called  "soldier's  heart."  The 
symptoms  are  weakness,  shortness  of  breath,  palpitation  and  dizziness.  Fre- 
quently there  is  a  region  of  hyperalgesia  over  or  near  the  heart.  It  is  suggested 
by  some  physicians  that  this  "disordered  action  of  the  heart"  is  a  form  of  the 
war  anxiety  neurosis.  Some  internists  state  that  fifty  per  cent  of  these  cases  are 
neurotics.  Among  cases  that  MacCurdy  has  examined  he  recognized  two  types 
that  correspond  roughly  to  the  anxiety  and  conversion  hysteria  groups.  The 
first  group  have  a  strong  desire  for  death  before  the  actual  appearance  of  the 
symptoms.  In  the  second  group  there  is  a  desire  for  an  incapacitating  wound 
and  the  heart  symptoms  are  looked  upon  as  a  disease  and  not  worried  about. 
On  the  whole  the  number  of  cases  of  purely  neurotic  heart  conditions  that  develop 
at  the  front  is  insignificant  when  compared  to  the  anxiety  states  and  common 
conversion  hysterias. 

In  conclusion,  MacCurdy  speaks  of  the  prophylactic  measures  to  be  taken  to 
prevent  such  great  loss  in  the  efficiency  of  the  army  as  war  neuroses  have  pro- 
duced. Careful  exclusion  of  the  unfit  at  the  time  of  enlistment  is  necessary,  but 
many  difficulties  arise  in  connection  with  this  method.  Often  the  man  best 
adapted  to  civil  life  is  not  capable  of  being  the  best  soldier.  On  the  other  hand, 
there  are  men  who  have  shown  histories  of  previous  breakdowns,  yet  who 
turned  out  to  be  fine  soldiers.  The  only  thing  to  be  done  is  to  exclude  all  those 
who  show  marked  psychopathic  tendencies  and  who,  at  the  time  of  enlistment, 
are  ill-adapted  to  civil  life.  It  would  be  well  if  the  physician  could  reexamine 
all  the  doubtful  cases  after  a  few  months  of  training  and,  if  they  have  improved, 
give  them  a  chance  at  the  front.  Another  point  of  importance  in  prophylaxis 
is  that  the  soldier  must  frequently  be  relieved  from  duty  and  be  given  as  many 
distractions  as  possible.  MacCurdy  says:  "At  the  present  time  the  line  officers 
of  the  British  Army  are  as  acutely  aware  of  the  necessity  for  rest  and  distraction 
as  are  the  physicians,  and  the  reason  for  this  is  that  they  have  discovered  that,  no 
matter  how  much  men  may  be  forced  and  no  matter  how  willing  they  may  be  to 
continue  in  the  trenches,  they  nevertheless  become  inefficient  when  subjected  to 
more  than  a  certain  amount  of  fatigue.  If  at  all  feasible,  a  system  of  relief 
should  be  worked  out  in  a  conference  between  psychiatrists  and  the  staff.  If 
also  practicable,  a  certain  laxity  in  the  arrangements  should  be  left  whereby 
psychiatrists  might  be  allowed  the  privilege  of  removing  certain  men  from  the 
trenches  earlier  than  they  would  their  fellows.  If  possible,  this  would  be  of 
great  military  advantage,  as  the  histories  of  many  patients  show  that,  when  they 
have  an  opportunity  to  rest,  they  quickly  recover  from  the  premonitory  symp- 
toms of  a  war  neurosis  and  return  to  fight  again  quite  competently.  Once  the 
disease  has  progressed  beyond  a  certain  point,  however,  there  seems  to  be  no 
return  except  after  a  long  period  of  treatment.  ...  It  goes  without  saying 
that  all  forms  of  comfort  and  distraction,  particularly  the  presence  of  palatable 
food  and  drink,  are  of  importance  from  a  medical  standpoint  in  the  present  war 
as  they  never  have  been  before.  Where  every  factor  seems  to  operate  in  making 
it  hard  for  the  soldier  to  maintain  his  adaptation — his  pleasure  in  the  service — 
it  is  essential  that  his  difficulties  should  be  reduced  to  a  minimum,  and  that,  on 
the  other  hand,  he  should  be  furnished  with  every  possible  means  for  giving  him 
that  pleasure  which  would  distract  his  mind  from  all  that  is  unpleasant  and 
horrible  around  him. 

"Finally,  when  men  are  sent  back  to  rest  camps  in  order  to  recover  from  their 
fatigue  it  would  be  highly  desirable  that  they  should  receive  an  examination 
before  they  return  to  active  duty  again.     As  has  been  shown  in  a  number  of 


79 

cases  in  this  report,  the  prospect  of  returning  to  duty,  when  recovery  has  not 
been  complete,  is  frequently  the  occasion  for  utter  discouragement  and  conse- 
quent collapse.  In  a  war  that  may  last  for  years  an  extra  week  or  even  an  extra 
month  of  absence  from  the  trenches  is  less  loss  to  the  army  than  is  that  which  is 
occasioned  by  the  protracted  convalescence  wliich  follows  only  a  week,  per- 
haps, of  efficient  service.  Here  again  the  problem  is  reduced  to  a  question  of 
adapting  indi\'idual  treatment  to  the  miUtary  necessities  that  consider  all  men 
alike." 

In  the  course  of  the  article  twenty-seven  case  histories  are  described  in  detail. 

Neymann,  Clarence  A.     Some  Experiences  in  the  German  Red  Cross. 
Mental  hygiene  i :  392-96,  July  1917 

After  a  five  years'  residence  in  Germany  the  writer  had  just  finished  liis  state 
examinations  at  Heidelberg  and  entered  the  department  of  hygiene  to  study 
serology  when  the  war  broke  out.  He  was  persuaded  to  join  the  German  Red 
Cross,  where  he  remained  untU  the  end  of  April  1915. 

He  states  that  during  the  early  period  of  the  war,  in  fact,  until  the  battle  of  the 
Marne,  not  a  single  mental  case  was  received  at  the  hospital  where  he  was  sta- 
tioned. This,  he  thinks,  was  probably  due,  partly  to  the  attitude  of  the  German 
army,  buoyantly  sure  of  speedy  victory,  and  partly  to  the  fact  that,  on  account  of 
this  feeling,  no  provision  had  been  made  for  specialized  treatment  of  any  kind, 
so  that  no  attention  was  paid  to  soldiers  who  behaved  in  queer  waj's.  When  the 
fighting  changed  from  open  to  trench  warfare  the  whole  situation  was  changed. 
Hardly  a  transport  of  sick  and  wounded  arrived  but  contained  its  quota  of  mental 
cases.  The  psycliiatric  clinic  was  used  only  for  patients  with  serious  mental 
aflBictions  so  psychoneurotics  had  to  be  treated  at  base  hospitals.  When  the 
hospitals  had  no  psycliiatrist  on  their  staff,  these  psychoneurotics  were  looked 
upon  as  nuisances,  so  were  transferred  to  the  evacuation  hospitals,  where  they 
"stagnated"  for  a  while,  and  were  eventually  returned  to  the  front.  There  all 
their  sj'mptoms  returned  immediately  and  they  were  returned  to  the  base  hos- 
pitals. Sometimes  single  men  made  this  circuit  as  many  as  three  times.  Fi- 
nally the  government  took  charge  of  the  matter  and  assigned  to  each  base  hospital 
a  psychiatrist  or  arranged  for  regular  visits  from  one  in  the  vicinity.  These 
psychiatrists  dealt  also  with  cases  of  slackers.  The  government  also  issued  a 
proclamation  warning  against  returning  psychoneurotic  patients  to  the  front, 
and  recommending  various  duties  for  them  in  the  rear  or  at  home.  This  caused 
a  great  improvement  in  conditions. 

One  t^-pe  of  psychoneurosis  was  particularly  frequent  and  noticeable.  It  was 
called  Granatfieber,  grenade  fever.  All  suffering  from  it  seemed  poorly  built 
physically  and  constitutionally  weak.  They  complained  of  indigestion,  back- 
ache, and  headache,  grew  pale  and  trembled,  and  in  some  cases  lost  control  of 
their  legs  and  fell  to  the  ground  whenever  grenades  were  mentioned  or  expe- 
riences on  the  firing  line  related. 

Another  class  of  cases  consisted  of  individuals  who  had  had  very  trying  ex- 
periences which  had  led  them  to  simulate  some  mental  or  physical  disorder  for 
which  others  had  been  sent  to  the  rear.  Sometimes  this  simulation  was  kept  up 
for  months.  "It  is  hardly  to  be  wondered  at  that  a  man  who  naturally  has  not 
much  strength  of  character  grows  tired  after  months  of  trench  life  and  quits, 
either  by  purposely  exposing  himself  to  the  fire  of  the  enemy,  or  by  simulating 
some  disorder.     All  such  individuals  were  considered  unfit  for  duty  at  the  front." 

A  third  tj^jc  are  those  slightly  deficient  mentally.  The  trooi)s  from  Bavaria 
are  notably  brave,  yet  among  their  wounded  one  finds  many  high-grade  morons. 
These  individuals  have  as  a  rule  not  proven  bad  soldiers. 

"Of  course  there  were  all  sorts  of  individual  reactions.  Those  patients  who 
had  gone  through  depressions  in  previous  years  again  became  depressed.     Hypo- 


80 

manic  individuals  became  very  wild  and  lost  almost  the  last  remnants  of  civili- 
zation. .  .  .  After  a  rest  in  the  hospital  for  a  period  of  time  they  usually 
calmed  down  again  and  became  manageable." 

Salmon,  Thomas  W.    Use  of  Institutions  for  the  Insane  as  Military 
Hospitals.    Mental  hygiene  i :  354-63,  July  191 7 

The  British  War  Office  asked  the  Board  of  Control  in  January  1915  to  co- 
operate in  an  attempt  to  provide  50,000  beds  for  wounded  soldiers.  A  plan 
was  formulated  whereby  ninety-two  countj'^  and  borough  asylums  were  divided 
into  ten  groups  and  one  institution  in  each  group  vacated  for  military  use. 
Major  Salmon  quotes  in  full  "Circular  A — Use  of  Asylums  as  Military  Hos- 
pitals", describing  a  scheme  prepared  by  the  Board  of  Control  for  the  general 
administration  of  vacated  asylums  and  the  details  of  reimbursement  which  the 
War  Office  undertook  to  make  to  receiving  and  vacated  institutions  of  this  kind. 
This  is  followed  by  "Circular  B — Use  of  Asylums  as  Military  Hospitals",  giving 
in  detail  observations  by  the  War  Office  supplementary  to  their  general  con- 
firmation of  the  scheme  described  in  Circular  A.  The  first  employment  of  this 
plan  made  about  12,000  beds  available,  and  by  July  1,  1917,  27,158  beds  were 
ready  for  use  by  the  War  Office.  Even  when  a  military  hospital  was  to  be  used 
for  insane  soldiers,  the  name  was  changed  from  "asylum"  to  "hospital"  so  that 
the  patients  should  escape  the  "stigma"  of  having  been  treated  in  an  institution 
for  mental  disease. 

A  list  of  these  converted  institutions  follows.  The  total  cost  of  turning  over 
these  hospitals  was  not  ascertained.  In  the  case  of  the  Norfolk  Asylum  it 
amounted  to  $90,000.  The  capacity  of  the  institutions  was  almost  invariably 
increased. 

Major  Salmon  next  describes  the  changes  in  personnel  and  administration 
necessitated  by  the  new  use  to  which  the  institutions  were  put.  Most  of  the 
buildings  were  of  the  cottage  or  small  detached  building  tj^pe. 

This  article  is  embodied  as  Appendix  II  in  Major  Salmon's  report  upon  the 
"Care  and  Treatment  of  Mental  Diseases  and  War  Neuioses  ("Shell  Shock") 
in  the  British  Army." 

Yerkes,  Robert  M.     Relation  of  Psychology  to  Military  Activities. 
Mental  hygiene  i :  371-76,  July  1917 

The  article  describes  briefly  a  few  of  the  many  lines  of  service  for  national 
defense  open  to  the  psychologist.  The  WTiter  says:  "Since  the  psychologist 
deals  especially  with  the  conscious  activity  of  men,  he  should  be  a  master  in  the 
description  and  valuation  of  human  nature  and  an  expert  in  the  measurement  of 
significant  aspects  of  human  response.  In  this  capacity,  recruiting  offers  him  an 
important  special  task;  that  namely,  of  classifying  men  according  to  their  mental 
characteristics,  and  of  indicating  their  degree  of  adequacy  for  military  training 
or  special  tasks  in  the  military  organization.  By  means  of  especially  developed 
and  adapted  methods  of  psychological  examining,  it  should  be  possible  to  gain 
information  concerning  each  individual  upon  which  may  be  based  important 
recommendations  to  medical  or  to  line  officers." 

Major  Yerkes  believes  that  certain  grades  of  mental  defectives  need  not  be 
excluded  from  military  service,  but  that  suitable  places  may  be  found  for  them 
in  military  as  well  as  industrial  organizations.  Another  point  realized  by  psy- 
chologists is  the  unsuitability  to  military  requirements  of  many  of  the  current 
methods  for  psychological  examination,  and  the  necessity  for  preparing  new  and 
specially  adapted  methods.  "In  connection  with  the  preliminary  handling  of  re- 
cruits, it  is  the  prospective  function  of  the  examining  psychologist  first,  to  aid 
in  the  elimination  of  those  who  cannot  safely  render  service  worth  their  hire; 
second,  to  indicate  various  degrees  and  kinds  of  special  ability  and  to  relate 


81 

them  to  the  tasks  of  army  and  navy,  so  that  each  individual  shall  be  placed  in 
a  position  of  maximum  usefulness;  and  third,  to  detect  those  who,  by  reason  of 
mental  instability  or  psychopathic  condition,  demand  the  attention  of  the 
medical  expert.  Such  individuals  should  be  referred  to  the  staff  of  the  neuro- 
psychiatric  hospital  unit  for  special  study." 

In  conclusion  the  writer  outlines  a  few  of  the  military  applications  of  psy- 
chological measurements,  such  as  in  the  study  of  gunnery,  and  the  examination 
of  aviation  recruits. 

Journal  of  Amer.  med.  assoc.  69:  1458,  Oct.  27,  1917.    The  War  and 
General  Paralysis  (Paris  Letter,  Sept.  27,  191 7) 

The  three  Paris  societies  which  are  devoted  to  the  study  of  mental  diseases, 
the  Societe  clinique  de  medecine  mentale,  the  Societe  medico-psychologique  and 
the  Societe  de  psychiatric,  recently  held  two  joint  meetings  to  discuss  two  im- 
portant questions  in  military  mental  medicine;  the  discharge  of  men  with  gen- 
eral paralysis;  and  shell  shock  with  its  special  etiology,  evolution  and  sequels, 
A  whole  session  was  devoted  to  each  of  these  questions  in  turn,  with  M.  Justin 
Godart,  undersecretary  of  state  for  the  military  medical  service,  in  the  chair  at 
one  meeting,  and  Dr.  Simonin,  medical  inspector,  presiding  at  the  second  meet- 
ing- 

The  discussion  on  the  discharge  of  soldiers  with  general  paralysis  was  brought 
about  by  the  extremely  severe  rule  voted  by  the  Societe  de  neurologic  in  Decem- 
ber, 1916,  on  this  subject,  and  by  the  too  literal  application  of  tliis  rule  by  the 
medical  men  entrusted  with  the  task  of  passing  on  the  candidates  for  discharge 
from  the  army.  The  society  had  officially  declared  that  every  soldier  with 
general  paralysis  should  be  granted  discharge  no.  2,  except  when  he  had  been 
the  victim  of  traumatism  of  the  brain,  in  which  case  discharge  no.  1  should  be 
granted  with  an  incapacity  rate  of  from  10  to  30  per  cent. 

Dr.  Pactet,  in  the  leading  address,  demonstrated  that  a  doctrinal  question 
was  responsible  for  the  vote  of  the  Societe  de  neurologic,  namely,  the  belief  that 
general  paralysis  is  exclusively  syphilitic  in  its  origin.  But  to  be  syphilitic  is  not 
enough  to  bring  on  general  paralysis.  Can  any  one  affirm  that  the  fatigues,  the 
emotions,  the  dangers  of  the  war  do  not  play  a  part  in  localizing,  aggravating 
and  accelerating  the  production  of  the  meningo-encephalitis?  Instead  of  re- 
garding en  bloc  all  the  cases  of  general  paral^'sis,  each  should  be  given  a  separate 
examination,  and  in  each  individual  case  the  effort  should  be  made  to  estimate 
the  part  for  which  the  circumstances  of  war  are  responsible,  just  as  is  being  done 
for  the  tuberculous.  The  military  authorities  must  be  asked  for  the  data  as  to 
the  services  imposed  on  the  patient,  and  if  the  general  paralysis  seems  to  have 
been  influenced  by  them,  then  grant  discharge  no.  1,  with  a. pretty  high  rate  of 
incapacity.  Dr.  Lepine,  professor  of  nervous  and  mental  diseases  at  Lyons,  de- 
clared his  views  as  entirely  in  accordance  with  those  of  Dr.  Pactet.  Dr.  Dupr6, 
agrege  professor  at  Paris  and  hospital  physician,  insisted  on  the  exclusively 
syphilitic  origin  of  general  paralysis,  and  demanded  that  discharge  no.  I  should 
be  reserved  for  cases  in  which  some  grave  war  mishap  could  be  invoked. 

Dr.  Marie,  physician-in-chief  to  the  public  Asiles  of  the  Seine  deparlment. 
and  Lortat-Jacob,  Paris  hospital  physician,  gave  a  description  of  the  general 
paralysis  of  wartime  as  running  a  much  shorter  course,  with  no  interniission, 
with  repeated  sudden  attacks,  and  with  an  early  fatal  outcome,  skipping  the 
stage  of  helpless  dementia.  Dr.  Vallon,  physician-in-chief  of  the  Asile  Sainte 
Anne,  reiterated  that  the  interests  of  the  patients  must  not  be  sacrificed  to  too 
absolute  theories — "fragile,  like  all  theories."  In  the  question  of  discharge  from 
the  military  service,  as  in  all  medicolegal  problems,  each  case  must  be  studied 
separately,  and  the  men  on  active  service  should  not  be  treate<l  any  less  favor- 
ably than  workmen  becoming  paralyzed  after  an  industrial  accident. 


Dr.  Rubinovitch,  physician-in-chief  of  the  Bicetre  and  Salpetriere  hospitals, 
expatiated  on  the  lessons  to  be  learned  from  the  Russo-Japanese  War,  which  led 
to  recrudescence  of  cases  of  paretic  dementia  in  the  army.  Dr,  Colin,  physician- 
in-chief  of  the  insane  asylum  at  Villejuif,  presented  an  array  of  exact  data  re- 
garding the  cases  of  general  paralysis  in  soldiers  that  he  has  had  in  his  charge. 
He  remarked  further  that  wounds  of  the  brain  are  spoken  of  always  as  authoriz- 
ing discharge  no.  1,  but  in  this  connection  it  must  be  borne  in  mind  that  general 
paralysis  has  never  been  observed  in  men  wounded  in  the  brain.  The  physicians 
on  the  military  discharge  commissions  interpret  in  the  narrowest  sense  the  term 
traumatisme  enciphalique.  The  restrictions  in  question  will  not  be  applicable  to 
more  than  a  small  proportion  of  the  patients — not  over  15  per  cent — the  majority 
of  cases  being  among  the  territorials,  the  noncombatants.  He  then  specified 
some  cases  in  which  the  routine  application  of  discharge  no.  2  would  constitute 
a  revolting  injustice. 

The  following  rule  was  finally  definitely  adopted  by  a  unanimous  vote.  For 
men  with  general  paralysis,  accord  discharge  no.  2,  except  in  special  cases  in 
which  a  careful  inquiry  would  demonstrate  in  times  of  peace,  and  more  especially 
in  time  of  war,  the  aggravating  influence  of  military  service.  The  rate  of  dis- 
ability should  then  be  from  60  to  80  per  cent. 

Mayer,  Alfred  G.  On  the  Non-Existence  of  Nervous  Shell  Shock  in 
Fishes  and  Marine  Invertebrates.  Proc.  U.  S.  National  acad. 
sciences.  3:  597,  Oct.  1917 

Mayer's  experiments  at  Tortugas,  Florida,  during  the  summer  of  1917, 
indicate  that  the  nervous  system  of  fishes  and  invertebrates  are  remarkably 
resistent  to  the  injurious  effects  of  sudden  explosive  shocks  transmitted 
through  the  water.  Many  experiments  were  made  on  the  Scyphomedusa 
Cassiopea  Xamachana.  The  medusae  were  paralysed  by  removing  their  mar- 
ginal sense  organs,  and  then  a  ring-shaped  strip  of  sub-umbrella  tissue  was  set 
into  pulsation  by  an  induction  shock,  thus  producing  a  single  neurogenic  con- 
traction which  travels  through  the  circuit-shaped  strip  of  tissue  at  a  uniform 
rate  of  speed,  provided  that  temperature,  salinity,  and  other  factors  remain 
unchanged.  It  is  thus  possible  to  ascertain  accurately  not  only  the  rate  of 
nerve  conduction,  but  also  the  peculiar  individual  characteristics  of  the  wave 
in  each  pulsating  ring.  These  rings  were  placed  in  a  light  silken  bag  immersed 
about  ten  feet  below  the  surface  of  the  sea;  and  then  half  a  stick  of  dynamite  was 
exploded  within  three  feet  of  them.  This,  however,  produced  no  effect  either 
upon  their  rates  or  the  characters  of  their  pulsation  waves,  although  fishes  pos- 
sessing swim-bladders  were  killed  within  ten  feet,  and  injured  so  that  they  turned 
ventral  side  uppermost  within  twenty  feet  of  the  exploding  dynamite.  When 
the  pulsating  rings  were  placed  in  glass  jars  or  tin  cans,  partially  filled  with  air, 
the  containers  were  crushed  or  shattered  by  the  explosion,  and  much  mechanical 
injury  suffered  by  the  medusa  rings,  which,  however,  could  at  once  be  restored 
to  normal  pulsation  by  an  induction  shock  if  their  pulsations  had  ceased.  It 
was  also  observed  that  the  lacerated  area  regenerated  at  a  normal  rate.  Experi- 
ments proved  that  fishes  with  swim-bladders  are  more  sensitive  to  explosive 
shocks  than  those  without  swim-bladders;  thus  a  half  stick  of  dynamite  exploded 
within  3  feet  of  a  small  shark,  which  has  no  swim-bladder,  produced  no  apparent 
injury:  this  applied  also  in  a  lesser  degree  to  such  taleosts  as  lack  swim-bladders. 
Dr.  Ball  dissected  some  of  the  swim-bladder  fishes  killed  by  the  explosion;  he 
found  that  the  swim-bladder  had  burst,  and  the  tissues  were  crushed  in  around 
it,  the  vertebral  column  being  often  broken.  It  seems,  then,  that  in  the  lower 
forms  the  injurious  effects  of  dynamite  explosions,  when  present,  are  due  to 
mechanical  laceration  of  tissues,  and  especially  the  crushing  inward  of  air-filled 
cavities.     "It  seems  possible,  therefore,  that  the  cavities  of  the  middle  ear  and 


88 

Eustachian  tubes  may  be  a  source  of  clanger  to  men  standing  near  exploding 
shells."  The  writer  thinks  that  his  experiments  with  the  pulsating  rings  of 
Cassiopea  negative  the  suggested  hypothesis  that  the  sudden  reduction  in  atmos- 
pheric pressure  close  to  an  exploding  shell  might  set  free  dissolved  gases  in  the 
blood  and  elsewhere,  thus  vacuolating  the  tissues  and  producing  pressure  and 
other  effects  upon  the  nerves;  for  no  injurious  effects  other  than  those  of  simple 
asphyxiation  were  produced  by  a  sudden  exhaustion  of  the  air  surrounding  the 
animals;  and  recovery,  when  they  were  placed  in  normal  sea  water,  was  almost 
immediate.  He  holds  that  these  results  are  in  accord  with  the  conclusions  of 
Grasset,  Eder,  Babinski  and  Froment,  and  others,  that  war  shock  is  predomi- 
nantly a  psychic  phenomenon,  and  being  hysteria  it  can  be  cured  by  hypnotic 
suggestion. — L.  J.  Kidd,  Rev.  of  neurology  and  psychiatry  15:  335-37,  Aug.- 
Sept.  1917. 

Salmon,  Thomas  W.  Care  and  Treatment  of  Mental  Diseases  and 
War  Neuroses  ("Shell  Shock")  in  the  British  Army.  Mental 
hygiene  i:  509-47,  Oct.  1917 

The  article  consists  of  sections  of  Major  Salmon's  report  on  his  recent  visit  to 
England,  together  with  an  appendix  entitled  "Facilities  Needed  for  Efficient 
Treatment  of  Mental  Diseases  in  a  Modern  Public  Institution."  For  abstract 
of  the  full  report  see  p.  92-96, 

Hammond,  Graeme  M.  Neurological  and  Mental  Examination  of 
State  Troops  of  the  National  Guard.  Address  at  meeting  of  the 
New  York  Neurological  Society,  Nov.  13,  191 7 

Major  Graeme  M.  Hammond,  M.D.,  M.R.C.,  gave  a  general  review  of  the 
work  he  had  been  doing  in  examination  of  the  troops  of  the  National  Guard  in 
this  city  and  at  the  camps.  When  he  received  orders  in  August  from  the  Sur- 
geon General  to  examine  all  the  militia  in  the  vicinity  of  New  York  City,  he 
was  at  first  unprepared  to  act,  for  he  realized  his  own  efforts  could  be  so  small  in 
such  a  tremendous  task.  So  he  enlisted  the  interest  and  assistance  of  twelve 
able  neurologists  and  psychiatrists  who  agreed  to  help  him  in  the  work  and  they 
formed  themselves  into  an  examining  board. 

The  troops  were  scattered  throughout  the  armories  here  and  in  camps  in  the 
Bronx  and  Van  Cortlandt  Park,  but  the  work  was  started,  beginning  with  one 
regiment.  The  army  surgeons  with  the  troops  could  give  little  information  as 
to  the  mental  soundness  of  the  men,  though  they  knew  all  about  their  physical 
conditions,  but  it  was  soon  discovered  that  the  non-commissioned  oflScers  could 
give  a  certain  amount  of  such  information,  so  these  men,  usually  sergeants,  were 
asked  to  make  lists  of  the  men  whom  they  believed  would  not  make  good  sol- 
diers. That  helped  a  great  deal.  Soon  experience  showed  that  many  of  the 
candidates  could  be  passed  at  a  glance  on  the  appearance  they  presented,  but 
others  were  given  a  more  careful  examination.  The  intention  was  to  dispose 
of  those  who  would  not  make  good  soldiers,  who  would  not  obey  orders,  or  who 
could  not  understand  them,  those  with  no  idea  of  discipline,  those  with  organic 
disease  of  the  nervous  system,  and  the  mentally  unstable  cases.  Certain  regi- 
ments were  found  to  have  higher  types  of  men  than  others;  very  few  were  re- 
jected from  some  regiments,  but  in  one,  from  a  distant  part  of  the  country, 
sixty-three  per  cent  were  rejected.  After  the  Rainbow  Division  left,  nearly 
4,000  men  had  been  through  this  examination. 

At  the  camps  the  work  was  not  easy,  for  large  numbers  had  to  be  examined 
in  a  day,  though  some  of  these  men  were  of  an  exceedingly  high  class  and  one 
had  no  difficulty  in  deciding  that  they  were  all  right.  But  some  were  delin-. 
quents,  though  not  mental  defectives;  others  were  manic  depressives;  there  were 


84 

cases  of  dementia  precox,  epilepsy,  and  migraine,  a  few  spinal  cases,  some  of 
progressive  muscular  atrophy,  though  only  one  of  cerebrospinal  syphilis.  No 
cases  of  tabes  were  seen.  In  some  regiments  there  were  many  cases  of  goitre,  a 
few  of  them  exophthalmic,  but  unless  they  presented  constitutional  symptoms 
they  had  not  been  rejected;  only  when  they  showed  evidence  of  tremor  or  of 
physical  weakness  so  that  they  could  not  keep  up  with  their  work,  were  they 
considered  unfit  for  duty. 

One  could  hardly  realize  the  amount  of  work  this  meant.  The  large  number 
of  men  that  had  to  be  rejected  proved  a  revelation.  The  army  was  full  of  in- 
competents who  should  have  been  stopped  before  they  entered  if  the  men  on  the 
exemption  boards  had  done  their  duty,  and  it  was  deeply  to  be  regretted  that 
such  a  state  of  affairs  should  exist  in  this  age  and  at  this  crisis.  In  the  officers' 
training  camp  there  were  many  whom  it  was  found  necessary  to  reject,  men  of 
the  highest  type,  college  men,  and  those  who  had  held  important  positions,  men 
of  affairs.  Those  from  the  West  compared  very  favorably  with  those  from  New 
York  State,  but  in  one  regiment  of  men  from  a  large  city,  many  of  the  men  had 
been  in  jail  or  a  reformatory.  The  cases  of  migraine  were  of  interest,  mostly 
all  giving  a  significant  family  history,  usually  the  mother  having  suffered  from  it. 
Those  who  had  slight  attacks  were  passed,  but  those  in  whom  the  attacks  lasted 
two  or  three  days  accompanied  by  severe  pain  and  prostration,  were  rejected. 
Epileptics  were  not  rejected  unless  they  were  seen  during  a  seizure  by  a  member 
of  the  Board,  or  by  some  one  on  whose  testimony  the  Board  could  rely.  A 
proportion  of  those  would  probably  be  heard  from  later.  There  was  no  doubt 
that  a  certain  number  of  cases  of  all  kinds  that  should  have  been  rejected  got 
through.  In  recognition  of  the  Surgeon  General's  opinion  that  such  men  were 
not  desirable,  they  had  been  careful  in  going  over  the  neurasthenics  and  those 
with  hysteria. 

As  far  as  the  militia,  the  volunteer,  regiments  were  concerned,  they  would 
undoubtedly  prove  a  high  type  of  soldier,  but  in  regard  to  the  National  Army 
as  a  whole  one  could  not  be  so  enthusiastic.  In  one  day  seventeen  men  were 
dismissed  from  the  service  who  had  been  under  observation  in  the  psychiatric 
hospital  at  one  camp  for  a  number  of  days.  This  was  where  the  heroin  cases 
were  seen,  some  of  them  coming  in  voluntarily  because  they  could  not  obtain 
the  drug  and  others  sent  in  by  the  commander.  It  was  a  matter  of  astonishment 
how  frequently  these  men  were  supplied  with  this  substance  by  visiting  friends 
and  relatives.  Of  the  seventeen  rejected  men  referred  to,  four  were  cases  of 
dementia  precox;  four,  epileptics;  eight,  heroin  habitues;  and  one  was  undiag- 
nosed.—N.  Y.  med.  j.  107:  764-65,  April  20,  1918. 

Hunt,  J.  Ramsay.    Exhaustion  Pseudo-paresis ;  Address  at  a  Meeting 
of  the  New  York  Neurological  Society,  Nov.  13,  1917 

Dr.  J.  Ramsay  Hunt  presented  a  resume  of  the  results  of  special  neuropsy- 
chiatric  examinations  in  one  of  the  large  training  camps  for  officers,  composed 
of  1,500  men,  and  out  of  this  number  eleven  cases  were  found  presenting  slight 
but  definite  symptoms  of  incipient  paresis,  preparesis,  or  early  cerebral  syphilis, 
a  diagnosis  confirmed  by  examinations  of  the  blood  and  cerebrospinal  fluid. 
Generally  speaking  the  clinical  symptoms  were  not  very  marked,  consisting  of 
pupillary  changes,  tremors  of  the  face  and  hands,  and  shght  disturbances  of 
articulation  on  repeating  test  phrases.  The  usual  cerebral  symptoms  or  evi- 
dence of  mental  deterioration  were  so  slight  as  to  be  practically  negligible  from 
the  diagnostic  standpoint,  and  in  studying  this  very  important  group  of  cases 
the  examiner  was  almost  wholly  dependent  upon  those  silent  but  well  established 
somatic  symptoms  of  early  paresis  so  characteristic  to  the  trained  observer;  i.  e., 
tremors,  absent  or  feeble  reactionto  light  and  disorders  of  articulation  of  the 
paretic  type. 


85 

As  directly  bearing  on  this  subject,  emphasis  was  laid  upon  the  occurrence  of 
another  group  of  cases  which  had  come  under  observation,  tj;ie  formal  recogni- 
tion of  which  was  of  importance  because  of  the  close  similarity  of  the  somatic 
symptoms  to  those  of  early  paresis.  This  condition  was  apparently  dependent 
upon  an  exhaustion  of  the  cerebrospinal  centres  as  a  result  of  the  unusual  strain, 
both  mental  and  physical,  to  which  men  undergoing  the  intensive  course  of 
military  training  were  subjected.  Four  cases  were  reported  in  detail,  presenting 
slight  mental  and  cerebral  disturbances,  inequality  of  the  pupils,  with  extremely 
feeble  and  sluggish  reactions  to  light,  coarse  tremors  of  the  hands,  face  and 
tongue  and  a  dysarthric  disturbance -of  speech  on  repeating  test  phrases  very 
similar  to  that  observed  in  the  early  stage  of  paresis.  The  pupils  in  all  of  the 
cases  were  unequal  and  showed  a  very  feeble  and  sluggish  reaction  to  light.  In 
some  of  the  cases  there  was  so  little  response  as  to  suggest  a  true  loss  of  the  light- 
reaction.  The  reaction  on  accommodation  was  preserved  and  the  sympathetic 
response  was  also  elicitable;  the  impression  of  an  Argyll- Robertson  pupil  was, 
therefore,  produced.  The  tremors  of  the  face  and  tongue  were  coarse,  with 
associated  movements  of  the  facial  muscles  on  speaking.  In  addition,  fairly 
coarse  tremors  of  the  hands  and  fingers  were  present  and  handwTiting  was 
tremulous.  Syllable  stuttering  and  the  dysarthric  speech  of  paresis  were  closely 
simulated. 

Clinically,  the  diagnosis  of  incipient  paresis  seemed  assured,  but  the  serological 
examinations  of  the  blood  and  spinal  fluid  were  entirely  negative.  There  was 
no  increase  of  globulin  or  cells,  and  the  colloidal  gold  reaction  was  negative. 
Furthermore,  all  the  sjTnptoms  cleared  up  after  a  week  or  ten  days'  rest.  In 
the  absence,  therefore,  of  positive  findings  in  the  blood  and  spinal  fluid  and  the 
rapid  improvement  under  rest,  it  seemed  clear  that  the  condition  had  been 
produced  by  an  acute  exhaustion  of  the  central  nervous  system,  with  somatic 
symptoms  strongly  suggestive  of  early  paresis. 

As  there  was  association  between  fatigue  and  the  production  of  certain  toxins 
which  act  upon  the  central  nervous  system  as  well  as  upon  the  muscles,  in  addi- 
tion to  the  theory  of  nerve  exhaustion,  a  lowgrade  intoxication  of  the  nerve 
centres  had  to  be  considered  as  a  possible  explanation.  Among  these  toxic 
products  of  fatigue  might  be  mentioned  such  substances  as  carbon  dioxide, 
paralactic  acid  and  monopotassium  phosphate.  .  .  .  Some  observers, 
notably  Weichardt,  had  also  long  maintained  that  a  specific  fatigue  intoxication 
existed,  and  was  the  essential  etiological  factor  in  the  production  of  its  character- 
istic manifestations. 

Among  the  recognized  mental  symptoms  of  fatigue  was  a  diminished  power 
of  attention,  a  lack  of  ability  to  concentrate,  a  slow  reaction  to  mental  stimuli, 
slowness  in  reasoning,  as  well  as  errors  and  slowness  in  mathematical  calculation. 
If  these  symptoms  were  present  in  any  marked  degree  and  associated  with  the 
somatic  symptoms  mentioned  above,  they  might  well  lead  to  error. 

It  is  well  known  that  fatigue  is  a  frequent  cause  of  tremor,  and  tremor  after 
prolonged  muscular  activity  is  well  recognized.  The  unusual  degree,  wide 
distribution  and  persistence  of  it  in  these  fatigue  cases  were  probably  dependent 
upon  the  prolonged  mental  and  physical  strain  and  a  special  disposition  to 
exhaustibility  of  the  nerve  centres. 

As  the  mechanism  of  speech  requires  a  delicate  coordination  of  the  higher 
cortical  centres  and  muscular  activity,  it  is  perhaps  not  suqirising  that  the 
disturbance  of  arti(,'ulation  noted  in  this  group  of  cases  should  have  oc-curred  as 
a  manifestation  of  extreme  fatigue. 

More  difficult  of  explanation  were  the  pupillary  phenomena.  It  was  well 
known  that  during  the  convulsive  crises  of  epilepsy,  and  even  hysteria,  the 
pupils  diluted  and  were  rigid  to  light.  Also,  in  simple  exhaustion,  the  ]>upils 
were  dilated  and  might  be  sluggisii  to  light,  witii  reservation  uf  the  reaction  on 
accommodation.    Perhaps  the  suspicious  pupillary  phenomena  observed  in  these 


86 

exhaustion  cases  were  of  a  somewhat  similar  nature,  possibly  dependent  upon  a 
disturbance  of  the  sympathetic  innervation  of  the  pupil  by  fatigue  or  the  toxins 
of  fatigue.  The  pupils,  while  definitely  unequal,  with  sluggish  or  absent  reac- 
tion to  light,  presented  no  irregularities  of  contour,  and  this  might  constitute 
an  important  point  of  difference  from  the  true  syphilitic  pupil  which  not  infre- 
quently displays  marginal  irregularities. 

Dr.  Hunt  stated  that  he  had  not  observed  a  similar  condition  in  civil  practice, 
which  he  ascribed  to  the  unusual  etiological  conditions  furnished  by  life  in  a 
training  camp,  and  thought  that  the  formal  recognition  of  a  fatigue  syndrome 
simulating  early  paresis  was  worthy  of  earnest  consideration.  Furthermore,  it 
was  not  unlikely  that  under  still  greater  conditions  of  stress  and  strain  this 
group  might  be  the  forerunner  of  more  severe  types  of  the  exhaustion  neuroses 
and  neuropsychoses. — J.  A.  M.  A.  70:  11-14,  Jan.  5,  1918. 

Salmon,  Thomas  W.    Neurology  and  Psychiatry  in  the  Army;  Address 
at  a  meeting  of  the  New  York  Neurological  Society,  Nov.  13,  191 7 

The  address  consisted  chiefly  of  an  account  of  the  work  in  neurology  and  psy- 
chiatry already  done  in  armies,  and  that  which  is  being  planned  for  the  future. 
Many  illustrations  from  the  present  war  were  given,  showing  the  great  signifi- 
cance of  the  problem  of  mental  disease  in  military  services.  This  country  has 
profited  by  the  experience  of  foreign  armies  in  their  attempts  to  solve  the  prob- 
lem, for  Surgeon  General  Gorgas  made  appropriations,  even  before  the  partici- 
pation of  the  United  States  in  the  war,  for  the  organization  of  neurological  and 
psychiatric  work  in  the  Army  upon  a  scale  never  before  attempted.  The  Med- 
ical Reserve  Corps,  assisted  by  the  War  Work  Committees  of  the  National  Com- 
mittee for  Mental  Hygiene,  of  the  American  Medico-Psychological  Association, 
and  of  the  American  Neurological  Society,  has  commissioned  222  specialists  in 
nervous  and  mental  diseases  to  serve  in  the  various  camps  in  this  country.  Med- 
ical ofiicers  stationed  at  all  officers'  training  camps  conduct  examinations  of  all 
candidates  for  commissions,  with  the  result  that  many  cases  of  organic  nervous 
disease  and  some  of  psychoses  and  psychoneuroses  have  been  rejected  for  disa- 
bility. At  each  of  the  National  Army  cantonment  camps  is  a  neuropsychiatric 
board  composed  of  three  medical  officers  to  examine  cases  referred  to  them  by 
line  and  medical  ofiicers.  In  addition  to  these  tests,  a  system  for  the  examina- 
tion of  civilians  in  training  has  been  inaugurated.  This  will  weed  out  cases  of 
unfitness  before  the  forces  are  sent  abroad,  consequently  decreasing  greatly  the 
number  of  those  who  would  otherwise  have  to  be  returned  to  this  country  for 
treatment  and  disability.  Up  to  the  time  when  the  address  was  delivered,  sev- 
eral thousand  men  had  already  been  rejected  for  various  forms  of  mental  and 
nervous  unfitness,  including  mental  defect,  epilepsy,  and  almost  all  the  psychoses. 
Seven  American  specialists  are  in  England  studying  shell  shock  and  methods  for 
its  care  and  treatment.  The  expeditionary  forces  in  France  have  several  others, 
one  is  attached  to  each  base  hospital  abroad,  one  to  each  military  prison,  and 
one  will  be  in  each  delinquency  battalion,  when  such  are  formed. 

Special  intensive  com-ses  in  neurology  and  psychiatry  have  been  taken  by 
several  of  these  medical  officers  who  felt  that  they  needed  special  training  or 
review  of  previous  theoretical  or  laboratory  work. 

A  brief  description  was  given  of  the  arrangements  to  be  made  abroad  for  the 
care  of  functional  nervous  cases  from  the  expeditionary  forces,  and  of  those  likely 
to  be  returned  to  the  United  States.  Major  Salmon  announced,  with  the  Sur- 
geon General's  permission,  the  opening  in  the  near  future  of  the  first  military  psy- 
chiatric hospital  in  this  country  at  Fort  Porter,  Buffalo.  Others  will  be  opened 
according  to  future  need.  A  special  neuropsychiatric  unit,  with  a  personnel  of 
216  trained  physicians,  nurses  and  special  workers  with  actual  experience  in  the 
care  and  treatment  of  nervous  and  mental  cases,  has  been  organized  and  will  sail 
soon  to  take  charge  of  a  special  neuropsychiatric  base  hospital  abroad. 


87 

In  conclusion  Major  Salmon  spoke  of  the  great  influence  that  this  work  in 
military  neuropsychiatry  is  bound  to  exert  upon  the  application  of  neurology 
and  psycliiatry  to  civil  problems  and  conditions  after  the  war. 

Anderson,  John  E.  Psychological  Tests  in  the  National  Army;  Ad- 
dress at  a  Meeting  of  the  Boston  Society  of  Psychiatry  and  Neu- 
rology, Dec.  20,  1917 

As  Lieutenant  William  S.  Foster,  of  Camp  Devens,  was  unable  to  present  a 
communication  on  the  above  topic,  Lieutenant  John  E.  Anderson  discussed  the 
examinations  of  the  men  at  that  camp.  He  said  that  a  psychological  examina- 
tion had  been  made  on  practically  every  man  in  camp.  The  object  of  the  exam- 
ination is  two-fold:  to  classify  the  mental  ability  of  the  men  as  an  aid  to  their 
superiors  in  the  selection  of  men  for  appointment  as  non-commissioned  officers 
and  for  special  duties,  and  secondly  to  weed  out  the  unfit. 

The  men  appear  for  the  examination  in  groups  of  from  one  hundred  to  two 
hundred.  First  a  very  brief  literacy  examination  is  given  wliich  separates  the 
illiterate  from  the  literate.  The  latter  then  take  a  forty-five  minute  test  cover- 
ing quite  varied  abilities.  The  illiterates  are  given  a  "skill  examination"  con- 
sisting of  the  putting  together  of  disassembled  implements,  such  as  locks, 
wrenches,  electric  bells,  and  so  on.  Those  doing  poorly  in  either  examination 
are  recalled  and  examined  individually.  If  their  performance  is  poor  enough 
to  warrant  it  they  are  sent  to  the  psychiatrist  who  examines  them  with  a  view 
to  rejection. 

On  the  basis  of  these  examinations  the  men  are  grouped  in  five  classes :  the 
very  superior,  su|>erior,  average,  inferior,  and  very  inferior.  The  company  com- 
mander receives  a  report  on  each  man,  to  be  used  in  any  way  he  sees  fit.  He 
is  advised  that  these  tests  get  at  the  "intelligence  factor"  only,  and  that  the 
final  selection  of  a  man  depends  also  upon  such  qualities  as  resourcefulness, 
leadership,  and  courage,  which  cannot  be  measured  by  tests.  But  the  tests  do 
bring  a  number  of  the  men  to  the  fore  who  otherwise  would  pass  unnoticed  and 
so  serve  to  give  the  officei  the  material  from  which  to  select.  This  has  been  par- 
ticularly noticeable  in  the  cases  of  quiet  but  efficient  men.  Each  company  com- 
mander submits  a  return  report  to  the  psychologists  in  which  he  comments  on 
the  usefulness  of  the  test  ratings  and  any  irregularities  he  has  noticed.  These 
reports  have  been  very  encouraging. 

Although  the  personnel  work  {i.  e.,  the  ratings  submitted  to  the  officers)  is  of 
primary  importance,  the  elimination  of  the  mentally  unfit  plays  a  large  part. 
The  psychologists  and  the  psychiatrists  cooperate  in  this  work. 

Asked  about  the  details  of  the  examinations.  Lieutenant  Anderson  said  that 
about  150  men  could  be  examined  an  hour  in  the  groups.  The  examination  in- 
cluding the  seating  and  arrangement  of  the  men  takes  an  hour.  The  individual 
examination,  given  to  the  culls  from  the  entire  system  of  examination,  takes 
between  forty  minutes  and  an  hour.  The  scoring  of  the  group  examinations, 
which  is  done  by  clerks  with  stencils  upon  wliich  the  correct  answers  are  desig- 
nated, takes  very  little  time.  The  tests  include  such  things  as  the  carrying  out 
of  simple  commands,  memory  for  digits,  the  rearrangement  of  sentences,  arith- 
metic prololems,  etc.,  all  aimed  to  give  ratings  on  general  intelligence. 

Asked  about  the  cost  of  the  examinations.  Lieutenant  Anderson  said  that  it 
was  very  small  as  compared  with  that  of  otlier  examinations  in  the  army.  He 
said  that  a  considerable  number  of  the  illiterates  had  been  found.  Many  of 
these  are  foreigners  who  have  difficulty  with  the  English  language.  Asked 
about  the  possibility  of  coaching  before  the  examinations,  he  said  that  five  dif- 
ferent forms  are  in  use,  and  that  the  examination  is  such  that  even  a  repetition  of 
it  gives  only  a  slightly  liigher  rating. — J.  nerv.  and  raeut.  dis.  47:  i2^3-!i4.  March 
1918. 


88 

Salmon,  Thomas  W.  War  Neuroses  ("Shell  Shock") ;  Lectures,  Illus- 
trated with  Motion  Picture  Films,  Prepared  by  Direction  of  the 
Surgeon  General  for  Use  in  the  Medical  Officers'  Training  Camps. 
N.  Y.  Natl.  comm.  mental  hygiene,  1917.  Also  in  Mil.  surg.  41: 
674-93)  I)ec.  1917 

Major  Salmon  treats  his  subject  under  two  main  divisions:  "Nature  and 
importance  of  the  neuroses  in  war";  and  "Diagnosis  and  treatment." 

"Military  life,"  he  says,  "has  well  been  called  'the  touchstone  of  insanity'. 
Not  only  in  actual  war,  but  even  in  peaceful  mobilizations,  such  as  that  of  our  own 
Army  along  the  Mexican  border  last  year,  there  is  a  higher  rate  of  mental  disease 
among  soldiers  than  in  civil  life.  The  discharge  rate  for  mental  diseases  in  the 
United  States  Army  in  1916  was  three  times  the  admission  rate  for  these  disorders 
in  the  adult  male  population  of  the  state  of  New  York,  one-tenth  of  all  discharges 
for  disability  being  for  mental  diseases,  mental  deficiency,  epilepsy,  and  the 
neuroses.  When  it  is  remembered  that  the  later  decades  of  life,  in  wliich  mental 
diseases  dependent  upon  organic  changes  in  the  brain  are  so  prevalent,  are  not 
represented  in  military  forces,  it  is  seen  that  the  rate  in  the  army  is  greater  even 
than  is  indicated  by  such  statistics." 

After  a  brief  discussion  of  the  peculiarly  difiicult  problems  in  adaptation 
created  by  military  life  for  neurotic  or  psychopathic  individuals,  the  extraordi- 
nary prevalence  of  the  neuroses,  fairly  common  in  civil  life,  but  a  major  medical 
problem  in  war  time,  is  commented  upon.  Although  no  new  symptoms  or 
diseases  are  exhibited  by  cases  of  war  neuroses,  or  shell  shock,  the  magnitude  of 
the  problem  makes  it  necessary  that  every  medical  officer  should  become  familiar 
with  it  from  the  point  of  view  of  diagnosis,  management  and  military  juris- 
prudence. 

Since  the  term  "shell  shock"  has  unfortunately  been  applied  rather  loosely  to 
practically  any  nervous  condition  in  soldiers  exposed  to  shell-fire,  which  is  in- 
explicable by  a  physical  injury,  and  has  even  been  used  to  include  types  of  mental 
disease,  a  division  of  these  conditions  into  some  etiological  and  clinical  groups  will 
help  to  clarify  the  subject.  Cases  in  which  the  soldiers  have  been  actually  ex- 
posed to  the  effects  of  high  explosives  include : 

1.  Cases  of  death  without  external  signs  of  injury.  Apparently  death  in  such 
cases  is  sometimes  due  to  damage  to  the  central  nervous  system. 

2.  Cases  exhibiting  severe  neurological  symptoms  in  characteristic  syndromes 
suggesting  the  operation  of  mechanical  factors,  such  as  concussion,  aerial  com- 
pression, the  rapid  decompression  following  it,  "gassing",  etc. 

3.  Cases  in  which  the  symptoms  are  those  of  neuroses  familiar  in  civil  practice^ 
but  distinctly  colored  by  war  experience.  Much  controversy  exists  as  to  the 
mechanism  of  such  cases  of  shell  shock. 

4.  Cases  in  which  even  the  slightest  injury  to  the  nervous  system  from  the 
explosion  is  improbable  and  in  which  the  war  experience  has  not  varied  at  all 
from  that  of  hundreds  of  comrades  who  have  developed  no  symptoms. 

There  is  still  another  group  of  cases  in  which  soldiers  who  have  not  been  ex- 
posed at  all  to  battle  conditions  develop  symptoms  almost  identical  with  those 
in  men  who  are  supposed  to  be  suffering  from  the  effects  of  actual  shell-fire. 
Farrar  calls  these  "anticipatory"  neuroses. 

"It  is  the  opinion  of  most  psychiatrists  and  neurologists  who  have  been  study- 
ing and  treating  'shell  shock'  in  the  British  Army,  that  the  last  two  groups  named 
are  by  far  the  largest  and  most  important  and  that,  whatever  the  unknown  physi- 
ological basis,  psychological  factors  are  too  obvious  and  too  important  in  these 
cases  to  be  ignored."  In  support  of  this  view  Major  Salmon  states  a  series  of 
significant  facts  based  upon  observations. 

"The  psychological  basis  of  the  war  neuroses  (like  that  of  the  neuroses  in  civil 
life)  is  an  elaboration,  with  endless  variations  of  one  central  theme — escape  from 
an  intolerable  situation  in  real  life  to  one  made  tolerable  by  the  neuroses.     Either  a 


89 

function  is  lost,  the  absence  of  which  releases  the  patient  from  the  intolerable 
situation,  or  one  is  lost  which  interferes  with  successful  adaptation.  The  function 
may  be  mental  or  physical."  Major  Salmon  outlines  several  cases  from  civil 
life  illustrating  the  mechanism  of  these  neuroses.  Needless  to  say,  the  same 
conflict,  in  an  exaggerated  form,  takes  place  in  modern  warfare.  Among  avenues 
of  escape  from  intolerable  situations  are  wounds,  capture  and  malingering.  The 
last  is  "  a  military  crime  that  is  not  at  the  disposal  of  men  governed  by  the  higher 
ethical  considerations.     .     . 

"  One  of  the  most  important  features  of  the  wide  employment  of  the  term  'shell 
shock'  to  denote  the  nevu-oses  in  war  is  its  implication  of  a  cause  acting  suddenly." 
Major  Salmon  then  shows  how  "shell  shock"  is  really  the  culmination  of  a  train 
of  symptoms,  arising  often  from  various  preexisting  conditions,  such  as  strain  and 
exhaustion,  personal  misfortunes,  or  a  neurotic  or  psychopathic  temperament. 

These  constitutionally  predisposed  individuals  naturally  contribute  most 
heavily  to  the  neuroses  among  soldiers,  but  men  with  apparently  sound  constitu- 
tions and  no  previous  mental  or  nervous  breakdowns  are  also  often  stricken 
after  exhausting  or  distressing  war  experiences.  Thus  in  shell  shock  the  situa- 
tion, apparently  a  very  simple  one  in  which  mechanical  factors  predominate,  is 
often  in  reality  exceedingly  complex  and  closely  involved  with  the  life  experience 
of  the  individual. 

In  discussing  the  symptomatology  of  war  neuroses,  Major  Salmon  includes 
neither  cases  of  organic  damage  to  nerve  tissue  nor  those  suffering  from  transitory 
nervous  symptoms  which  are  curable  by  a  short  rest.  The  distribution  of  the 
various  types  of  war  neuroses  varies  according  to  rank.  Officers  generally  suffer 
from  neurasthenia,  excessive  fatigue  both  of  body  and  mind,  irritability,  anxiety, 
and  fears  not  directly  connected  with  war  experiences.  Less  common  are  forms 
of  hysterical  paralysis  or  tremor.  The  most  striking  war  neuroses  are  those 
presenting  the  classical  symptoms  of  hysteria  in  a  new  and  often  dramatic  setting. 
"No  symptom  fatniliar  to  the  neurological  clinic  is  lacking  among  the  hundreds  of 
cases  of  shell  shock  to  be  found  in  the  military  hospitals  in  France  and  Eng- 
land. ...  In  those  cases,  which  have  as  their  starting-point  a  definite  shell 
or  mine  explosion,  there  are  often  symptoms  which  suggest  concussion.  Uncon- 
sciousness, dizziness,  deafness,  motor  incoordination,  and  such  physical  symp- 
toms as  amnesia,  confusion  and  hallucinations  of  hearing  make  up  the  so-called 
concussion  syndrome. "  Psychical  symptoms  are  transitory  delirium,  amnesia, 
mental  confusion,  hallucinations  and  vivid  "battle  dreams".  Among  speech 
disorders  are  aphasia,  stammering,  mutism  and  aphonia.  Sensory  symptoms  are 
anesthesia,  pain  and  hyperesthesia.  IJlindness,  night-blindness,  deafness, 
hyperacusis  and  anosmia  are  frequently  found,  also  disturbances  of  gait,  con- 
tractures, and  many  forms  of  paralysis  and  tremor.  Disturbances  of  involuntary 
functions  include  tachycardia,  enuresis  and  diarrhoea. 

The  C[uestion  of  diagnosis  is  most  important,  not  only  in  promoting  the  interest 
of  the  patients  but  also  that  of  the  military  service.  It  is  often  very  difficult  to 
distinguish  organic  disease  and  also  malingered  symptoms  from  the  somatic 
manifestations  of  hysteria.  Major  Salmon  mentions  a  few  of  the  more  impor- 
tant features  in  differential  diagnosis.  "Hysterical  speech  disorders  usually  pre- 
sent few  difficulties  in  diagnosis.  Aphasias  are  always  paradoxical  and  accom- 
panied by  other  hysterical  symptoms.  Stammering  comes  on  su<ldenly  with  no 
history  of  similar  speech  disturbance  in  youth.  Aphonia  may  be  shown  to  be 
functional  by  a  careful  laryngological  examination.  Visual  symptoms  do  not 
correspond  to  any  organic  cerebral  lesions  and  the  eye  is  found  to  b«'  normal  ex- 
cept for  contraction  of  the  visual  fields,  especially  the  helicoid  form  so  churacter- 
istic  of  hysteria.  In  the  rare  instances  in  which  disturbances  of  taste  are  found 
there  is  a  complete  bi-latcral  ageusia — a  syrnptom  unknown  except  in  hyslena 
or  unilateral  loss  corresponding  with  skin  anesthesia,  a  condition  which  dues  not 
occur  in  organic  disease. 


90 

"  Gait  disturbances  not  accompanied  by  paralysis  usually  simulate  abnormal 
locomotion  from  physical  disease  or  injury.  Thus  the  gait  may  resemble  that  of 
congenital  dislocation  of  the  hip-joint,  anchylosis  of  the  knee  or  ankle,  or  hip 
joint  disease — all  conditions  which  can  very  readily  be  excluded. 

"Paralyses  may  resemble  superficially  any  type  seen  in  organic  nervous 
lesions,  but  never  accurately.  Sometimes  difficulties  are  presented,  but  usually 
a  careful  neurological  examination  will  make  the  situation  clear.  While  atrophy 
may  exist  in  hysterical  paralyses  of  long  duration,  such  cases  are  unlikely  to  come 
to  attention  in  military  practice  except  in  the  examination  of  recruits,  and  the 
electrical  reactions  will  present  error.  The  reflexes,  especially  the  plantar  and 
bladder  reflexes,  are  of  the  greatest  value  in  determining  the  nature  of  a  paralysis. 
The  distribution  of  local  paralysis  seems  never,  even  by  accident,  to  correspond 
exactly  with  that  due  to  lesions  of  nerve  roots  or  peripheral  nerves.  The  pos- 
ture of  the  paralyzed  limb  is  rarely  similar  to  that  in  a  paralysis  due  to  an  organic 
lesion.  This  is  especially  well  shown  in  the  gait  in  hysterical  hemiplegia,  the 
foot  being  dragged  with  the  inner  instead  of  the  outer  border  of  the  sole  scraping 
along  the  floor.  The  enormous  predominance  of  left-sided  symptoms  in  hys- 
teria should  be  borne  in  mind. 

"The  anesthesias  of  hysteria  usually  present  no  serious  difficulties  in  diagno- 
sis. Although  it  is  not  possible  to  detect  all  of  them  by  such  a  simple  expedient 
as  asking  the  patient  to  say  '  yes '  when  he  feels  the  pin  and  '  no '  when  he  does 
not,  the  actual  reactions  elicited  are  often  quite  as  paradoxical.  It  is  helpful  to 
remember  that  the  patient  with  hysterical  anesthesia  never  suffers  from  his 
disability.  You  will  not  find  cuts  or  cigarette  burns  which  have  been  received 
without  knowing  it,  as  in  organic  cases. 

"In  the  examination  of  hysterics  it  must  be  remembered  that  pain,  anesthesia 
and  other  sensory  symptoms  are  true  hallucinations.  They  are  often  as  real  to 
the  patient  as  hallucinations  of  vision  or  hearing,  but  they  are  subject  to  as 
wide  variation  in  intensity  and  frequency.  Finally  one  should  be  mindful  of  the 
fact  that  rarely  hysteria  and  organic  disease  may  exist  together. 

"The  sudden  appearance  of  marked  incapacity  without  signs  of  injury,  in  a 
group  of  men  to  whom  invalidism  means  a  sudden  transition  from  extreme  dan- 
ger and  hardsliip  to  safety  and  comfort,  quite  naturally  leads  to  the  suspicion 
of  malingering.  The  general  knowledge  among  troops  of  the  more  common 
symptoms  of  'shell  shock'  and  of  the  fact  that  thousands  of  their  comrades 
suffering  from  it  have  been  discharged  from  the  army  sometimes  suggests  its 
simulation  to  men  who  are  planning  an  easy  exit  from  military  service  by  feign- 
ing disease.  It  is  therefore  of  much  military  importance  that  medical  officers 
be  not  deceived  by  such  frauds.  On  the  other  hand,  especially  before  the  clinical 
characters  and  remarkable  prevalence  of  war  neuroses  among  soldiers  had  be- 
come familiar  facts,  not  a  few  soldiers  suffering  from  these  disorders  were  exe- 
cuted by  firing  squads  as  malingerers.  Instances  are  also  known  where  hysterics 
have  committed  suicide  after  having  been  falsely  accused  of  malingering.  Mis- 
takes of  this  kind  are  especially  likely  to  occur  when  the  patients  have  not  been 
actually  exposed  to  shell  fire  because  the  idea  is  firmly  fixed  in  the  minds  of  most 
line  officers  and  some  medical  men  that  the  war  neuroses  are  always  due  to 
mechanical  shock. 

"The  diagnosis  between  neuroses  and  malingering  may  sometimes  be  ex- 
tremely difficult,  but  usually  it  is  easy  when  the  examiner  is  familiar  with  both 
conditions.  The  difficulties  arise  from  the  fact  that  in  both  a  disease  or  a  symp- 
tom is  simulated.  As  Bonnal  says,  '  The  hysteric  is  a  malingerer  who  does  not 
lie.'  The  cardinal  point  of  difference  is  that  the  malingerer  simulates  a  disease 
or  a  symptom  which  he  has  not  in  order  to  deceive  others.  He  does  this  consciously 
to  attain,  through  fraud,  a  specific  selfish  end — usually  safety  in  a  hospital  or 
discharge  from  the  military  service.  He  lies  and  knows  that  he  lies.  The  hysteric 
deceives  himself  by  a  mechanism  of  which  he  is  unaware  and  which  is  beyond  his 


91 

power  consciously  to  control.  He  is  usually  not  aware  of  the  precise  purpose  which 
his  illness  serves.  This  is  shown  by  the  fact  that,  in  many  cases,  all  that  is  nec- 
essary for  recovery  is  to  demonstrate  clearly  to  the  patient  the  mechanism  by 
which  his  disability  occurred  and  the  end  to  which,  unconsciously,  it  was 
directed. 

"There  are  a  number  of  distinctive  points  of  difference  betw^een  hysteria  and 
malingering,  two  of  which  it  may  be  interesting  to  mention. 

"1.  The  malingerer,  conscious  of  his  fraudulent  intent  and  fearful  of  its 
detection,  dreads  examinations.  The  hysteric  invites  them,  as  is  well  known  to 
physicians  in  civil  practice.  When  he  has  the  opportunity,  he  makes  the  rounds 
of  clinics  and  physicians,  especially  delighting  in  examinations  by  noted  spe- 
cialists. 

"2.  The  hysteric,  in  addition  to  the  symptoms  of  which  he  complains  often 
presents  objective  symptoms  of  which  he  is  unaware.  The  malingerer,  unless  of 
low  intelligence,  confines  his  complaints  to  the  disease  or  symptom  which  he  has 
decided  to  simulate. 

"Malingering  may  follow  or  prolong  a  neurosis.  This  is  not  infrequently  the 
case  when  mutism  is  succeeded  by  aphonia.  In  such  cases  the  clinical  picture 
presents  changes  very  apparent  to  the  experienced  psychiatrist,  but  it  must  be 
remembered  that  malingerers,  like  criminals  in  civil  life,  are  often  very  neuro- 
pathic individuals. 

"The  gravity  of  malingering  as  a  military  offense  in  an  army  in  the  field  justi- 
fies the  recommendation  that  no  case  in  which  the  possibility  of  a  neurosis  or 
psychosis  exists  be  finally  dealt  with  until  the  subject  is  examined  by  a  neurolo- 
gist or  psychiatrist.  If  neuropsychiatric  wards  are  provided  in  base  hospitals  in 
France  as  well  as  in  the  United  States,  such  an  examination  will  be  feasible  in 
practically  all  cases  without  causing  undue  delay.  The  knowledge  that  malinger- 
ers are  subjected  to  such  expert  examination  always  tends  to  discourage  soldiers 
from  this  practice." 

As  to  treatment,  Major  Salmon  emphasizes  the  fact  that  therapy  is  essentially 
a  psychological  problem,  the  first  step  of  which  is  a  careful  study  of  the  indi- 
vidual case.  The  attitude  of  the  medical  officer  is  also  of  great  importance.  He 
must  be  immune  to  surprise  or  chagrin,  firm  in  his  control  of  the  patient,  yet 
have  a  sane  and  understanding  sympathy.  "The  resources  at  the  disposal  of 
the  physician  in  treating  the  war  neuroses  are  varied.  The  patient  must  be 
re-educated  in  will,  thought,  feeling  and  function.  Persuasion,  a  powerful  re- 
source, may  be  employed  directly,  backed  by  knowledge  on  the  part  of  the 
patient  as  well  as  the  physician  of  the  mechanism  of  tlie  particular  disorder 
present.  Indirectly,  it  must  pervade  the  atmosphere  of  the  special  ward  or 
hospital  for  'shell  shock.'  Hypnotism  is  valuable  as  an  adjunct  to  persuasion 
and  as  a  means  of  convincing  the  patient  that  no  organic  disease  or  injury  is 
responsible  for  his  loss  of  function.  Thus  in  mutism  tlie  patient  speaks  under 
hypnosis  or  through  hypnotic  suggestion  and  thereafter  must  admit  the  int<'grity 
of  his  organs  of  speech.  The  striking  results  of  hypnotism  in  the  removal  of 
symptoms  are  somewhat  offset  by  the  fact  that  the  most  suggestible,  who  yield 
to  it  most  readily,  are  particularly  likely  to  be  the  constitutionally  neurotic.  In 
such  cases  we  are  using  to  bring  about  a  cure,  a  mental  mechanism  similar  to 
that  which  produced  the  disorder. 

"Recovery  within  the  sound  of  artillery,  or  at  least  'somewhere  in  France,* 
is  more  important  and  durable  than  that  which  takes  place  in  Kiigland.  This 
is  a  very  important  fact  and  the  brightest  spot  in  the  rather  dismal  ])i(turc 
presented  by  these  disorders.  .  .  .  For  severe  cases  and  those  which  t  iirough 
mismanagement  have  developed  the  unfortunate  secondary  symptoms  of  'shell 
shock'  and  in  whom  long-continued  treatment  is  necessary,  a  rural  ])lacc  is  best. 

"Reeducation  by  physical  means  is  a  valuable  adjunct  to  treatment  in  recent 
cases,  but  particularly  in  chronic  cases  who  have  been  mismanaged  and  in  those 


92 

who  are  recovering  from  long-continued  paralyses,  mutism  and  gait  disorders. 
While  drills  and  physical  exercises  have  their  specific  uses,  occupation  is  the 
best  means.    Non-productive  occupations  should  be  avoided." 

Occupations  may  be  divided  into  three  classes:  bed,  indoor,  and  outdoor. 
Under  class  1  may  be  included  basket  and  net  making,  preparation  of  surgical 
dressings,  and  various  minor  finishing  operations.  "All  occupations,  especially 
those  which  are  carried  on  by  patients  seriously  incapacitated,  should  be  re- 
garded only  as  steps  in  a  process  of  progressive  education.  Every  effort  must 
be  made  to  prevent  skill  acquired  in  them  from  being  considered  as  a  substitute 
for  full  functional  activity.  Herein  is  an  important  difference  between  the  re- 
education of  neurotic  and  orthopedic  cases."  Indoor  occupations  include 
carpentry,  wood  carving,  metal  and  cement  work,  printing,  bookbinding, 
cigarette  making,  and  electric  wiring.  Outdoor  work  may  consist  of  farming, 
gardening  and  building  operations,  wood  sawing  and  chopping,  and  the  care  of 
small  stock  not  requiring  much  land. 

"Before  even  the  simplest  occupation  can  be  engaged  in  it  is  sometimes  neces- 
sary to  reeducate  paraplegics  and  ataxics  in  walking  and  coordination.  Just 
as  soon  as  possible  exercises  should  be  replaced  by  productive  occupations  which 
will  accomplish  the  same  results  more  quickly  and  more  satisfactorily.  Thia 
is  true  of  gymnastic  exercises  which  in  the  early  steps  of  treatment  constitute  a 
valuable  resource  but  which  should  be  replaced  by  specially  devised  useful  tasks. 
Swimming  has  an  unique  place  in  the  treatment  of  gait  disturbances,  paralysis 
and  tics.  One  of  the  first  pieces  of  construction  undertaken  by  the  outdoor 
patients  at  a  reconstruction  center  should  be  that  of  building  a  large  concrete 
swimming  tank. 

"  Hydrotherapy  and  electrotherapy  have  a  distinct  value  when  they  are  applied 
with  absolute  sincerity  and  full  realization  on  the  part  of  the  patient  and  medical 
ofiicer  of  the  role  that  they  actually  play  in  the  treatment  of  functional  nervous 
diseases. 

"The  experience  of  English  hospitals  has  demonstrated  the  great  danger  of 
aimless  lounging,  too  many  entertainments  and  relaxing  recreations,  such  as 
frequent  motor  rides,  etc.  It  must  be  remembered  that  'shell  shock'  cases 
suffer  from  a  disorder  of  will  as  well  as  function  and  it  is  impossible  to  effect  a 
cure  if  attention  is  directed  to  one  at  the  expense  of  the  other.  As  Dr.  H. 
Crichton  Miller  has  put  it,  '  shell  shock '  produces  a  condition  which  is  essen- 
tially childish  and  infantile  in  its  nature.  Rest  in  bed  and  simple  encourage- 
ment is  not  enough  to  educate  a  chUd.  Progressive  daily  achievement  is  the 
only  way  whereby  manhood  and  self-respect  can  be  regained.' " 

Salmon,  Thomas  W.  Care  and  Treatment  of  Mental  Diseases  and 
War  Neuroses  ("Shell  Shock")  in  the  British  Army.  N.  Y., 
Natl.  comm.  mental  hygiene,  1917.    102  p.    Bibliography 

Major  Salmon  introduces  his  report  as  follows: 

"No  medico-military  problems  of  the  war  are  more  striking  than  those  grow- 
ing out  of  the  extraordinary  incidence  of  mental  and  functional  nervous  diseases 
('shell  shock').  Together  these  disorders  are  responsible  for  not  less  than  one 
seventh  of  all  discharges  for  disability  from  the  British  Army,  or  one  third  if  dis- 
charges for  wounds  are  excluded.  A  medical  service  newly  confronted  like  ours 
with  the  task  of  caring  for  the  sick  and  wounded  of  a  large  army  cannot  ignore 
such  important  causes  of  invalidism.  By  their  very  nature,  moreover,  these 
diseases  endanger  the  morale  and  discipline  of  troops  in  a  special  way  and  re- 
quire attention  for  purely  military  reasons.  In  order  that  as  many  rnen  as 
possible  may  be  returned  to  the  colors  or  sent  into  civil  life  free  from  disabilities 
which  will  incapacitate  them  for  work  and  self-support,  it  is  highly  desirable  to 
make  use  of  all  available  information  as  to  the  nature  of  these  diseases  among 


93 

soldiers  in  the  armies  of  our  allies  and  as  to  their  treatment  at  the  front,  at  the 
bases  and  at  the  centers  established  in  home  territory  for  their  reconstruction. 
England  has  had  three  years'  experience  in  dealing  with  the  medical  problems  of 
war.  During  that  time  opinion  has  matured  as  to  the  nature,  causes  and  treat- 
ment of  the  psychoses  and  neuroses  which  prevail  so  extensively  among  troops. 
A  sufficient  number  of  different  methods  of  military  management  have  been 
tried  to  make  it  possible  to  judge  of  their  relative  merits.  My  visit  to  England 
was  for  the  purpose  of  observing  these  matters  at  first  hand  so  that  I  might  con- 
tribute information  which  might  aid  in  formulating  plans  for  dealing  with  mental 
and  nervous  diseases  among  our  own  forces  when  they  are  exposed  to  the  terrific 
stress  of  modern  war. " 

The  report  does  not  include  any  account  of  the  treatment  of  organic  nervous 
diseases  nor  of  injuries  to  the  central  or  peripheral  nervous  systems,  nor  did 
Major  Salmon  have  time  for  any  original  clinical  observations. 

As  to  prevalence  of  mental  diseases  in  military  services  the  following  quotation 
will  be  of  interest ; 

"On  March  31,  1917,  about  1.1%  of  all  patients  in  the  military  hospitals  of 
Great  Britain  were  officially  diagnosed  as  insane.  The  percentage  among  expedi- 
tionary patients  was  1.3,  and  among  non-expeditionary  patients  1.1.  The  enor- 
mous prevalence  of  wounds  in  patients  from  the  expeditionary  troops  reduces  the 
percentage  of  all  other  conditions,  so  the  excess  of  mental  cases  among  expedi- 
tionary cases  is  much  greater  than  is  apparent.  Among  non-wounded  expedi- 
tionary patients  the  percentage  was  about  tliree  times  that  among  the  non-ex- 
peditionary cases.  The  rate  among  officers  was  only  one  third  that  among  men 
in  expeditionary  patients  and  about  the  same  in  non-expeditionary  patients. 
This  has  an  important  bearing  upon  the  fact  that  the  rate  for  the  war  neuroses 
('shell  shock')  is  four  times  as  high  among  officers  as  among  men.  .  .  .  It  can 
be  estimated,  from  all  the  data  available  that  the  annual  admission  rate  to  the 
British  miUtary  hospitals  for  the  insane  is  about  2  per  1,000  among  the  non- 
expeditionary  troops  and  about  4  per  1,000  among  expeditionary  troops.  The 
rate  in  the  adult  male  civil  population  of  Great  Britain  is  about  1  per  1,000." 

Several  special  war  hospitals  for  the  treatment  of  mental  cases  have  been  es- 
tablished in  the  United  Kingdom  through  the  taking-over  for  this  use  of  county 
and  borough  asylums.  This  subject  is  discussed  in  Appendix  II  of  Major  Sal- 
mon's report.  There  were  at  the  time  of  the  completion  of  the  report  about 
3,400  beds  in  strictly  military  hospitals  available  in  Great  Britain  and  Ireland 
for  insane  soldiers.  "No  attempt  has  been  made  to  care  for  the  insane  in  France, 
the  policy  of  the  War  Office  being  to  send  all  cases  to  the  clearing  hospital  at 
Netley  and  then  to  special  institutions  as  soon  as  possible.  There  are  available 
in  France  only  125  beds,  all  for  the  temporary  detention  of  mental  cases. " 

During  191G  the  number  of  mental  cases  passing  through  the  3,400  beds  avail- 
able for  their  care  in  Great  Britain  and  Ireland  was  about  (5.000. 

No  new  clinical  types  of  mental  disease  have  been  observed  in  armies.  "There 
are  no  'war  psychoses'.  The  clinical  pictures  familiar  in  civil  life  are  seen, 
colored  often  by  the  experience  at  the  front,  but  for  the  most  j)art  unchanged  in 
their  symptomatology,  outcome  and  course.  The  distribution  of  tlic  various 
psychoses  has  been  strikingly  different  from  that  in  civil  life,  but  this  has  been 
chiefly  due  to  the  different  age  periods  represented  in  patients  from  t lie  army. 
The  absence  of  the  organic  mental  diseases  of  the  later  decades  of  life,  which  play 
so  large  a  part  in  civil  statistics,  has  resulted  in  abnormally  high  percentages  for 
other  psychoses. " 

About  18%  of  the  patients  admitted  to  military  hospitals  for  mental  diseases 
have  been  found  mentally  defective.  Major  Salmon  believes,  in  s])ite  of  argu- 
ments advanced  to  the  contrary,  that  experience  in  the  present  war  has  proved 
that  mental  defectives  should  be  debarred  from  military  service  except  when  the 
last  available  man-power  must  be  utilized.     Under  such  circumstances,  they 


94 

should  be  kept  at  work  at  the  rear  under  the  supervision  of  non-commissioned 
oflBcers  specially  trained  in  their  management. 

Cases  of  general  paresis  amounted  to  about  2%  of  the  mental  patients  received 
in  special  hospitals.  Experience  in  the  British  Army  and  Navy  has  shown  that 
no  person  with  the  slightest  indication  of  syphilis  of  the  central  nervous  system 
should  be  enlisted  or  commissioned  for  any  military  duty. 

Manic-depressive  insanity  is  present  in  about  20%  of  all  admissions  to  military 
hospitals  for  mental  disease. 

Alcoholic  psychoses  are  now  found  almost  entirely  in  patients  on  leave  from 
the  front.  Delusional  types  appear  in  older  men  stationed  at  bases  where  oppor- 
timity  is  afforded  to  continue  life-long  habits  of  drinking  to  excess.  Attempted 
suicides  are  very  frequent  among  alcoholics  in  military  service.  Alcoholics 
should  be  debarred  from  the  service. 

Patients  suffering  from  dementia  precox  constitute  14%  of  admissions.  Most 
cases  appeared  shortly  after  enlistment  and  the  individuals  were  probably  psy- 
chopathic. 

Many  cases  of  epilepsy  observed  had  had  the  disease  before  enlistment. 

A  very  large  number  of  cases  of  constitutional  psychopathic  states  have  been 
received  in  the  special  military  hospitals  for  mental  diseases. 

As  to  prognosis.  Major  Salmon  says:  "There  are  no  statistics  available  to 
show  the  outcome  in  the  mental  diseases  treated  in  military  hospitals.  Dis- 
charge is  much  more  likely  to  be  regulated  by  administrative  considerations  than 
by  clinical  ones.  Acute  conditions  seem  to  recover  very  quickly.  Few  return 
'to  first  line  duty'.  The  statistics  indicate  a  much  larger  proportion  than  is 
actually  the  case.  The  number  of  those  who  go  back  to  the  colors  is  made  up  for 
the  most  part  of  patients  who  have  recovered  from  delirium  tremens  and  those 
with  war  neuroses  who  have  been  incorrectly  admitted  to  institutions  for  the 
insane.  Infective-exhaustive  psychoses  are  much  more  likely  to  be  regarded  as 
'shell  shock'  than  as  mental  disorders.  The  hospitals  for  mental  diseases  fail, 
therefore,  to  get  these  very  recoverable  cases  and  the  recovery  rate  in  such  in- 
stitutions suffers  correspondingly.     .     .     . 

"  For  the  United  States,  Great  Britain's  experience  carries  important  lessons. 
More  important  than  all  others  is  the  result  of  careless  recruiting.  The  problem 
of  dealing  with  mental  diseases  in  the  army — difficult  at  best — has  been  made  still 
more  so  by  accepting  large  numbers  of  recruits,  who  had  been  in  institutions  for 
the  insane  or  were  of  demonstrably  psychopathic  make-up.  The  next  most  im- 
portant lesson  is  that  of  preparing,  in  advance  of  an  urgent  need,  a  comprehen- 
sive plan  for  establishing  special  military  hospitals  and  using  existing  civil 
facilities  for  treating  mental  disease  in  a  manner  that  will  serve  the  army  effect- 
ively and  at  the  same  time  safeguard  the  interests  of  the  soldiers,  of  the  gov- 
ernment and  of  the  community." 

Section  II  of  Major  Salmon's  report  is  devoted  to  general  observations  upon 
the  nature  of  war  neuroses  or  shell  shock.  This  section  of  the  report  is  virtually 
a  more  detailed  discussion  of  the  same  subject  matter  as  the  pamphlet  by  Dr. 
Salmon  entitled  "War  Neuroses  (Shell  Shock)"  and  abstracted  on  p.  88-92,  so 
the  abstract  will  not  be  repeated  here. 

Section  III  is  entitled  "Recommendations  for  the  United  States  Army." 
Major  Salmon  says:  "It  seems  desirable  to  consider  separately  in  these  recom- 
mendations, expeditionary  and  non-expeditionary  forces.  It  is  necessary  to  deal 
separately  with  mental  and  nervous  diseases  in  the  United  States  but  not  in 
France.  While  facilities  existing  at  home  can  be  utilized  for  the  treatment  of 
mental  diseases,  it  is  necessary  to  create  new  ones  for  the  treatment  of  the  war 
neuroses.  In  France,  where  all  facilities  for  treatment  must  be  created  by  the 
medical  department,  the  distinction  between  psychoses  and  neuroses  need  not  be 
drawn  so  closely.  Consequently,  simpler  and  more  effective  methods  of  ad- 
ministrative management  can  be  devised". 


95 

One  important  feature  is  to  have  at  our  disposal  a  personnel  of  specially  trained 
medical  officers,  nurses  and  civilian  assistants  and  an  eflBcient  mechanism  for 
treating  mental  and  nervous  cases  in  France,  evacuating  them  for  continued 
treatment,  when  necessarj',  to  the  United  States. 

Most  important  is  the  rigid  exclusion  of  insane,  mentally  defective,  psycho- 
pathic and  neuropathic  men  from  expeditionary  forces. 

JMajor  Salmon  next  summarizes  his  recommendations  as  applied  to  the  expe- 
ditionary forces  as  follows: 

"  Overseas 

1.  Base  Section  of  Lines  of  Communication 

(a)  A  Special  Base  Hospital  of  500  beds  for  neuropsychiatric  cases,  located 
at  the  base  upon  which  each  army  (of  500,000-600,000)  rests.  These 
special  base  hospitals  to  be  used  for  cases  likely  to  recover  and  return  to 
active  duty  witliin  six  months.  Other  cases  to  be  cared  for  while  waiting 
to  be  evacuated  to  the  United  States. 

(b)  One  or  more  Special  Convalescent  Camps  in  connection  with  (and 
conducted  as  part  of)  each  Special  Base  Hospital. 

2.  Advanced  Section  of  Lines  of  Communication 

(a)  Special  Neuropsychiatric  Wards  of  30  beds  in  charge  of  three  psychi- 
atrists and  neurologists  for  each  base  hospital  having  an  active  service. 
These  wards  to  be  used  for  observation  (including  medico-legal  cases) 
and  for  emergency  treatment  of  mental  and  nervous  cases. 

(b)  Detail  of  a  psychiatrist  or  neurologist  attached  to  the  neuropsychiatric 
wards  of  base  hospitals,  to  evacuation  hospitals  or  stations  further  ad- 
vanced as  opportunities  permit. 

"  United   States 

1.  Mental  Diseases  (insane) 

(a)  One  or  more  Clearing  Hospitals  for  reception,  emergency  treatment, 
classification  and  disposition  of  mental  cases  among  enlisted  men  invalided 
home. 

(b)  Clearing  Wards  (in  connection  with  general  hospitals  for  oflBcers  or 
private  institutions  for  mental  diseases)  for  reception,  emergency  treat- 
ment, classification  and  disposition  of  mental  cases  among  ofl&cers  in- 
valided home. 

(c)  Legislation  permitting  the  Surgeon  General  to  make  contracts  with  pub- 
lic and  private  hospitals  maintaining  satisfactory  standards  of  treatment 
for  the  continued  care  of  oflScers  and  men  suffering  from  mental  diseases 
until  recommended  for  retirement  or  discharge  (with  or  without  pension) 
by  a  special  board. 

(d)  Appointment  of  a  special  board  of  three  medical  officers  to  visit  all 
institutions  in  wliich  insane  officers  and  men  are  cared  for  under  such  con- 
tracts to  see  that  adequate  treatment  is  being  given  and  to  retire  or  dis- 
charge (with  or  without  pension)  those  not  likely  to  recover. 

2.  War  Neuroses  {'shell  shock') 

(a)  Reconstruction  centers  (the  number  and  capacity  to  be  determined  by 
the  need)  for  the  treatment  and  re-education  of  such  cases  of  war  neuroses 
as  are  invalided  home.  Injuries  to  the  brain,  cord  and  peripheral  nerves 
to  be  treated  elsewhere. 

(b)  Special  convalescent  camps  where  recovered  cases  can  go  and  not  be 
subject  to  the  harmful  influences  for  those  cases  which  exist  in  camps  for 
ordinary  medical  and  surgical  cases. 

(c)  Employment  of  the  Spec-ial  Board  of  medical  officers,  recommended 
under  '1  (d)  '  to  visit  all  re-education  centers  and  convalescent  camps 
in  which  war  neuroses  are  treated  to  see  that  adequate  treatment  is  being 
given  and  to  retire  or  discharge  (with  or  without  pension)  those  not  likely 
to  recover." 


96 

This  summary  is  followed  by  a  detailed  discussion  of  each  recommendation. 
A  chart  illustrates  the  career  of  disabled  returned  soldiers. 

About  the  care  and  treatment  of  war  neuroses  and  mental  diseases  in  non-ex- 
peditionary forces,  Major  Salmon  says:  "Facilities  for  the  treatment  of  neuro- 
psychiatric  cases  at  the  camps  in  the  United  States  have  been  approved  by  the 
Surgeon  General  and  are  now  being  provided.  These  will  undoubtedly  prove 
suflBcient  for  dealing  temporarily  with  mental  cases  developing  in  the  non-ex- 
peditionary forces.  Their  final  disposition  should  be  made  by  means  of  the  same 
mechanism  recommended  for  expeditionary  patients  who  are  invalided  home, 
except  that  the  functions  of  the  clearing  hospital  for  mental  diseases  can  be  per- 
formed by  the  neuro-psychiatric  wards  of  divisional  hospitals  and  that  of  the 
special  board  by  the  Board  of  Survey  composed  of  the  neurologists  and  psychia- 
trists stationed  at  the  camps." 

Appendix  I  is  a  list  of  references  in  English  to  mental  diseases  and  war  neuroses 
and  their  treatment  and  management,  including  141  entries. 

Appendix  II  describes  the  use  of  institutions  for  the  insane  as  military 
hospitals.* 

Appendix  III  consists  of  a  directory  of  special  military  hospitals  for  mental 
diseases  and  war  neuroses  in  Great  Britain  and  Ireland. 

Appendix  IV  is  a  list  of  facilities  needed  for  efficient  treatment  of  mental 
diseases  in  a  modern  public  institution. 

Bost.  med.  and  surg.  j.  178:  24-25,  Jan.  3,  1918.    Organic  Lesions  in 
Shell-Shock  (Editorial) 

Recent  observations  on  the  various  fronts  tend  to  show  that  shell-shock 
is  the  expression  of  a  cell-exhaustion  of  the  central  nervous  system.  It  is 
generally  accepted  by  neurologists  that  this  exhaustion  is  accompanied  by  path- 
ological lesions  of  the  cytoplasm.  It  is,  perhaps,  doubtful  whether  this  change 
is  invariable,  and  the  laws  governing  it  are  still  very  imperfectly  known,  but,  as  a 
broad  fact,  it  is  certainly  true.  Such  lesions  may  be  divided  into  two  main 
groups.  First,  those  which  are  visible  after  proper  staining  of  some  particular 
cells  or  substance  of  the  brain.  These  have  been  observed  recently,  and  they 
seem  to  lie  at  the  root  of  fatal  cases  of  shell-shock.  Secondly,  those  which  con- 
note a  diminished  potentiality  for  the  development  of  nerve  force  of  such  a  nature 
as  to  impair  the  value  of  the  cell.  These  are  types  of  degeneracy  which  appear  in 
spite  of  a  satisfactory  military  training  and  environment.  It  is  this  latter  class 
that  alienists  like  Sir  George  Savage  and  Sir  Robert  Jones  have  described  in  the 
Journal  of  Mental  Science.  These  authors  seem  to  understand  by  the  disposition 
to  shell-shock  a  marked  falling  away,  mentally,  morally,  and  physically,  from  the 
average  condition  of  the  soldier  or  race.  Thus,  among  British  soldiers,  the  habit- 
ual criminal  and  the  morally  perverse,  the  mentally  unstable  and  insane,  the 
physically  weak  and  ill-developed  are  often  spoken  of  as  predisposed  to  shell- 
shock.  But  there  are  also  cases  in  which  it  occurs,  in  spite  of  hygienic  sur- 
roundings, the  best  heredity,  and  the  most  careful  education.  It  follows  that 
shock  or  fear  or  the  dread  of  the  "unknown,"  of  sufficient  severity  to  over- 
whelm the  will,  may  cause  in  healthy  men  the  whole  syndrome  of  the  affection 
— ^the  unconsciousness,  aphasia,  abasia,  and  pseudo-paraplegia.  It  is  shown 
by  Nissl  and  by  Nonne  that  the  power  to  resist  the  highest  degree  of  fear,  as  in 
drumfire,  explosion  of  mine  craters,  etc.,  necessitates  the  presence  of  the  maxi- 
mum nervous  potentiality  plus  an  optimum  constitution.  This  is  the  meaning 
of  Dr.  Mott's  phrase  that  many  cases  of  shell-shock  are  the  neuro-potentially 
unfit. 

There  are  three  chief  views  as  to  the  causation,  which  have  been  fully  discussed 
by  Wollenberg  (Archiv  fiir  Psychiatric,  1916,  p.  335),  and  more  recently  by  two 

*  For  abstract  of  Appendix  II,  see  p.  80,  Salmon,  Thomas  W.     Use  of  institutions,  etc. 


97 

Italian  neurologists,  Lattes  and  Goria  (Archivio  di  Antro-pologia  Criminale, 
April,  1917).  The  first  is,  that  shell-shock  is  not  the  expression  of  a  pathological 
cell  change,  but  the  sign  of  a  defect  which  exists  in  certain  strains  or  stocks,  and 
which  most  writers  describe  as  psychoneurosis,  hysteria,  suggestibility,  and 
degeneracy.  On  this  view  it  is  presumed  that  the  innate  nerve  potentiality  has 
been  impaired  by  congenital  or  acquired  hysteria  and  neurasthenia;  it  includes, 
besides,  the  types  of  degeneracy  as  seen  in  idiots,  epileptics,  and  paranoiacs. 
In  modern  armies  these  groups  are  found,  which  obviously  shows  the  importance 
of  a  minute  family  and  individual  history  in  the  examination  of  soldiers.  The 
second  view  is  that  the  syndrome  of  shell-shock  is  not  the  result  of  defects  or 
atavistic  causes,  but  arises  of  itself;  in  other  words,  it  is  psychogenic.  Most 
writers  agree  that  these  cases — the  functional,  emotional,  the  hysterical  in  the 
usual  sense — are  the  most  numerous.  As  Wollenberg  says:  "In  the  bulk  of  the 
cases  of  shell-shock  (Granatkontusion)  the  emotional  factor  far  outweighs  the 
commotional."  Dr.  Mott  and  other  British  authorities  take  this  view,  but  they 
have  considerably  narrowed  the  definition  of  hysteria. 

The  third  classification  is  that  the  causes  of  shell-shock — whether  they  have 
existed  ab  initio  in  the  soldier's  nervous  system  or  whether  thej'  are  psychogenic 
in  origin — are  physical  processes,  organic  lesions,  produced  by  the  effects  of  long 
exposure  to  the  gases,  and  other  results  of  the  bursting  of  powerful  shells.  In  this 
place  reference  may  be  made  to  a  recent  work  by  Homburger  (Die  korperlichen 
Erscheinungen  der  Kriegshysterie) .  This  author  looks  upon  the  question  in  a 
twofold  way;  either  the  idea  of  pure  hysteria  must  be  abandoned,  or  this  form  of 
hysteria  must  be  sharply  differentiated  from  hysteria  with  organic  lesions.  Most 
neurologists  at  the  front  find  it  exceedingly  difficult  to  believe  in  traumatic 
hysteria  (Oppenheim's)  or  molecular  shock  (Charcot's).  Actual  observers  found 
that  of  74  men  examined  after  an  artillery  attack,  67  showed  unmistakable  signs 
of  localized  organic  lesions  of  the  central  nervous  system. 

These  lesions  have  now  been  studied  post  mortem  by  Dr.  Mott  and  Captain 
Hurst.  They,  as  well  as  French,  Italian  and  Russian  neurologists  have  ob- 
served: (a)  Early  generalized  chromatolytic  changes  in  the  cells  of  the  central 
nervous  systeip,  (6)  disappearance  of  the  basophile  substances,  (c)  extravasation 
of  blood  into  the  substanceof  the  brain,  (d)  punctate  hemorrhages  with  congestion 
of  the  meninges,  (e)  minute  hemorrhages  and  changes  due  to  the  effects  of  com- 
pression and  decompression,  that  is  to  say,  as  in  caisson  disease,  with  cerebro- 
spinal fluid  under  high  pressure,  albumin,  blood,  and  excess  of  lymphocytes. 
It  has  been  noticed  by  several  observers  that  the  clinical  signs  are  those  of  or- 
ganic changes;  and  Homburger,  Morcher,  and  Nissl  believe  that  the  war  has 
altered  our  conceptions  of  hysteria  though  it  has  produced  no  new  tyjie.  Nissl, 
in  particular,  appears  to  question  the  existence  of  the  "hysterical  personality." 
Shell-shock  is  that  condition  of  nervousness  which  results  from  the  exhaustion  of 
the  inherent  vitality  of  the  cells.  They  are  unable  to  function  because  they 
have  come  to  the  end  of  their  physiological  banking  account.  In  fact,  to  Nissl 
most  cases  are  due  to  a  completely  human  and  normal  weakness,  and  the  organic 
lesions,  it  miglit  be  added,  arc  equally  likely  to  be  due  to  the  action  of  inorganic 
poisons,  as  gas,  and  physical  agents,  concussion  and  commotion. 

Bost.  med.  and  surg.  j,  178:60-62,  Jan.  10,  1918.    Shell-Shock  and 
the  American  Army  (Editorial) 

No  medico-military  problems  of  the  war  are  more  striking  than  those  growing 
out  of  the  extraordinary  incidence  of  mental  and  fuctional  nervous  diseases 
("shell-shock").  Together,  these  disorders  are  responsible  for  not  less  than 
one  seventh  of  all  discharges  for  disability  from  the  Britisli  Army,  or  one  third, 
if  discharges  for  wounds  are  excluded.     A  medical  service  newly  confronted, 


98 

like  ours,  with  the  task  of  caring  for  the  sick  and  wounded  of  a  large  army,  can- 
not ignore  such  important  cause  of  invaUdism.  By  their  very  nature,  moreover, 
these  diseases  endanger  the  morale  and  discipline  of  troops  in  a  special  way,  and 
require  attention  for  purely  military  reasons.  In  order  that  as  many  men  as 
possible  may  be  returned  to  the  colors  or  sent  into  civil  life  free  from  disabilities 
which  will  incapacitate  them  for  work  and  self-support,  it  is  highly  desirable  to 
make  use  of  all  available  information  as  to  the  nature  of  these  diseases  among 
soldiers  in  the  armies  of  our  allies,  and  as  to  their  treatment  at  the  front,  at  the 
bases,  and  at  the  centers  established  in  home  territory  for  their  "  reconstruction. " 

England  has  had  three  years'  experience  in  dealing  with  the  medical  problems 
of  the  war.  During  that  time,  opinion  has  matured  as  to  the  nature,  causes  and 
treatment  of  the  psychoses  and  neuroses  which  prevail  so  extensively  among 
troops.  A  sufficient  number  of  different  methods  of  military  management  have 
been  tried  to  make  it  possible  to  judge  of  their  relative  merits. 

Although  an  excessive  incidence  of  mental  diseases  has  been  noted  in  all  recent 
wars,  it  is  only  in  the  present  one  that  functional  nervous  diseases  have  consti- 
tuted a  major  medico-military  problem.  As  every  nation  and  race  engaged  is 
suffering  severely  from  these  disorders,  it  is  apparent  that  new  conditions  of  war- 
fare are  chiefly  responsible  for  their  prevalence.  None  of  these  new  conditions 
is  more  terrible  than  the  sustained  shell  fire  with  high  explosives  which  has  char- 
acterized most  of  the  fighting.  It  is  not  surprising,  therefore  that  the  term 
"shell-shock"  should  have  come  into  general  use  to  designate  this  group  of  dis- 
orders. The  vivid,  terse  name  quickly  became  popular,  and  now  it  is  applied  to 
practically  any  nervous  symptoms  in  soldiers  exposed  to  shell  fire  that  cannot  be 
explained  by  some  obvious  physical  injury.  It  is  used  so  very  loosely  that  it  is 
applied  not  only  to  all  functional  nervous  diseases,  but  to  well-known  forms  of 
mental  disease,  even  general  paresis.  If  all  neuroses  among  soldiers  were  included 
in  these  groups  the  use  of  the  term  "shell-shock"  might  be  defended.  But 
many  hundreds  of  soldiers  who  have  not  been  exposed  to  battle  conditions  at  all 
develop  symptoms  almost  identical  with  those  in  men  whose  nervous  disorders 
are  attributed  to  shell  fire.  The  non-expeditionary  forces  supply  a  considerable 
proportion  of  these  cases. 

The  medical  statistics  of  the  war  are  as  yet  untabulated.  Even  if  the  records 
contained  the  information  desired  it  would  be  very  difficult  to  state  the  preva- 
lence of  the  neuroses  on  account  of  the  defective  nomenclature  employed.  It  is 
doubtful  if  there  is  another  group  of  diseases  in  which  more  confusion  of  terms 
exists.  Nervous  or  mental  symptoms  coming  to  attention  after  the  soldier  has 
been  exposed  to  severe  shell  fire  are  almost  certain  to  be  diagnosed  as  "shell- 
shock,"  and  yet  when  such  patients  are  received  in  England,  well-defined  cases 
of  general  paresis,  epilepsy,  or  dementia  prsecox  are  often  found  among  them. 
This  source  of  confusion  tends  to  swell  the  number  of  cases  reported  under  the 
term  "shell-shock,"  but  there  are  many  other  sources  of  error  which  tend  to 
diminish  the  apparent  prevalence  of  the  war  neuroses.  It  is  the  belief  of  those 
who  have  made  an  effort  to  ascertain  the  prevalance  of  the  war  neuroses  that  the 
rate  among  the  expeditionary  forces  is  not  less  than  ten  per  thousand  annually, 
and  among  the  home  forces  not  less  than  three  per  thousand. 

The  experience  of  the  British  "shell-shock"  hospitals  emphasizes  the  fact 
that  the  treatment  of  war  neuroses  is  essentially  a  problem  in  psychological 
medicine.  While  patients  with  severe  symptoms  of  long  duration  recover  in 
the  hands  of  physicians  who  see  but  dimly  the  mechanism  of  their  disease,  and 
are  unaware  of  the  means  by  which  recovery  actually  takes  place,  no  credit  be- 
longs to  the  physician  in  such  cases  and  but  little  to  the  type  of  environment 
provided.  In  the  great  majority  of  instances  the  completeness,  promptness  and 
durability  of  recovery  depend  upon  the  insight  shown  by  the  medical  officers 
under  whose  charge  the  soldiers  come,  and  their  resourcefulness  and  skill  in 
applying  treatment. 


The  resources  at  the  disposal  of  the  physician  in  treating  the  war  neuroses  are 
varied.  The  patient  must  be  reeducated  in  will,  thought,  feeling,  and  function. 
Persuasion,  a  powerful  resource,  may  be  employed,  directly  backed  by  knowledge 
on  the  part  of  the  patient  as  well  as  the  physician  of  the  mechanism  of  the 
particular  disorder  present.  Indirectly,  it  must  pervade  the  atmosphere  of  the 
special  ward  or  hospital  for  "shell-shock."  Hypnotism  is  valuable  as  an  adjunct 
to  persuasion  and  as  a  means  of  convincing  the  patient  that  no  organic  disease 
or  injury  is  responsible  for  his  loss  of  function.  Thus,  in  mutism,  the  patient 
speaks  under  hj'pnosis  or  through  hypnotic  suggestion,  and  thereafter  must  ad- 
mit the  integrity  of  his  organs  of  speech.  The  striking  effects  of  hypnotism  in 
the  removal  of  symptoms  are  somewhat  offset  by  the  fact  that  the  most  suggesti- 
ble who  yield  to  it  most  readily  are  particularly  likely  to  be  the  constitutionally 
neurotic.  A  mental  mechanism  similar  to  that  which  produced  the  disorder  is 
being  used  in  such  cases  to  bring  about  a  cure. 

The  experience  in  English  hospitals  has  demonstrated  the  great  danger  of 
aimless  lounging,  too  many  entertainments  and  relaxing  recreations,  such  as 
frequent  motor  rides,  etc.  It  must  be  remembered  that  shell-shock  cases  suffer 
from  a  disorder  of  will  as  well  as  function,  and  it  is  impossible  to  effect  a  cure  if 
attention  is  directed  to  one  at  the  expense  of  the  other.  As  Dr.  H.  Crichton 
Miller  has  put  it,  "Shell-shock  produces  a  condition  which  is  essentially  childish 
and  infantile  in  its  nature.  Rest  in  bed  and  simple  encouragement  is  not 
enough  to  educate  a  child.  Progressive  daily  achievement  is  the  only  way 
whereby  manhood  and  self-respect  can  be  regained." 

It  is  evident  that  the  outcome  in  the  war  neuroses  is  good  from  a  medical  point 
of  view  and  poor  from  a  military  point  of  view.  It  is  the  opinion  of  all  those 
consulted  that,  with  the  end  of  the  war,  most  cases,  even  the  most  severe,  will 
speedily  recover,  those  who  do  not  being  the  constitutionally  neurotic  and 
patients  who  have  been  so  badly  managed  that  very  unfavorable  habit-reactions 
have  developed.  This  cheering  fact,  however,  brings  little  consolation  to  those 
who  are  chieflly  concerned  with  the  wastage  of  fighting  men.  The  lesson  to  be 
learned  from  the  British  results  seems  clear — that  treatment  by  medical  officers 
with  special  training  in  psychiatry  should  be  made  available  just  as  near  the 
front  as  military  exigency  will  permit,  and  that  patients  who  cannot  be  reached 
at  this  point  should  be  treated  in  special  hospitals  in  France,  until  it  is  apparent 
that  they  cannot  be  returned  to  the  firing-lines.  As  soon  as  this  fact  is  estab- 
lished, military  needs  and  humanitarian  ends  coincide.  Patients  should  then 
be  sent  home  as  soon  as  possible.  The  military  commander  may  have  the  sat- 
isfaction of  knowing  that  food  need  not  be  brought  across  to  feed  a  soldier  who 
can  render  no  useful  military  service,  and  the  medical  officer  may  feel  that  his 
patient  will  have  what  he  most  needs  for  his  recovery — home  and  safety  and  an 
environment  in  which  he  can  readjust. 

Although  it  might  be  considered  more  appropriately  under  the  heading  of 
prevention  than  under  that  of  treatment,  the  most  important  recommendation 
to  be  made  is  tiiat  of  rigidly  excluding  insane,  feeble-minded,  psychopathic  and 
neuropathic  individuals  from  the  forces  which  are  to  be  sent  to  France  and  ex- 
posed to  the  terrific  stress  of  modern  war.  Not  only  the  medical  officers  but 
the  line  officers  interviewed  in  England  emphasized,  over  and  over  again,  the 
importance  of  not  accepthig  mentally  unstable  recruits  for  military  service  at 
the  front.  If  the  period  of  training  at  the  concentration  camps  is  used  for  obser- 
vation and  examination,  it  is  witliin  our  power  to  reduce  very  materially  the 
difficult  prol)lem  of  caring  for  mental  and  nervous  cases  in  France,  increase  the 
military  efficiency  of  the  expeditionary  forces,  and  save  the  country  millions  of 
dollars  in  pensions.  Sir  William  Osier,  who  has  had  a  large  experience  in  the 
selection  of  recruits  for  the  British  Army  and  has  seen  the  disastrous  results  of 
carelessness  in  this  respect,  feels  so  strongly  on  the  subject  that  he  has  recently 
made  his  views  known  in  a  letter  to  the  Jovrnal  oj  the  Avicricaii  Medical  Asso- 


100 

ciation,  in  which  he  mentions  neuropathic  make-up  as  one  of  the  three  great 
causes  for  the  invariable  rejection  of  recruits.  In  personal  conversation  he  gave 
numerous  illustrations  of  the  burden  which  the  acceptance  of  neurotic  recruits 
had  unnecessarily  thrown  upon  an  army  struggling  to  surmount  the  difficult 
medical  problems  inseparable  from  the  war. 

Neuroses  are  very  common  among  soldiers  who  have  never  been  exposed  to 
shell  fire,  and  wiU  undoubtedly  be  seen  frequently  among  non-expeditionary 
troops  in  this  country.  In  England  nearly  thirty  per  cent  of  all  men  from  the 
home  forces  admitted  to  one  general  hospital  were  suffering  from  various  neuro- 
ses. Most  of  these  men  were  of  very  neurotic  make-up.  Many  had  had  pre- 
vious nervous  breakdowns.  Fear,  even  in  the  comparatively  harmless  camp 
exercises,  was  a  common  cause  of  neurotic  symptoms.  Heart  symptoms  were 
exceedingly  common.  The  same  experience  in  oiu"  own  training  camps  can  be 
confidently  predicted. 

Bailey,  Pearce.     War  and  Mental  Diseases.*     Amer.  j.  pub.  health 
8: 1-7,  Jan.  1918 

The  address  outlines  the  methods  used  by  the  medical  department  of  the 
United  States  army  in  meeting  the  problem  of  mental  and  nervous  troubles 
arising  in  connection  with  military  service. 

A  rather  elaborately  organized  psychiatric  service  has  been  established  to 
eliminate  the  unfit  and  to  care  for  mental  and  nervous  cases.  The  large  num- 
ber of  insane,  epileptics,  defectives,  etc.,  recorded  in  the  medical  history  of  former 
wars,  the  enormously  larger  porportion  in  the  present  war,  and  the  early  lack 
of  facilities  to  meet  the  problems  created  by  these  conditions  led  to  the  estab- 
lishment of  such  a  service  by  the  Surgeon  General  of  the  United  States  army. 
After  the  declaration  of  war  by  this  country,  specialists  in  these  lines  were  called 
for  to  take  commissions  in  the  medical  reserve  corps,  and  a  large  number  of 
volunteers  presented  themselves  for  the  work.  The  number  of  medical  reserve 
officers  holding  such  commissions  was  at  the  time  of  the  delivery  of  the  address 
more  than  200.  Some  were  stationed  at  the  various  camps,  some  went  abroad 
to  study  in  special  hospitals,  and  others  remained  in  the  United  States  to  do 
work  in  special  clinics. 

The  types  of  mental  and  nervous  cases  found  in  connection  with  military 
service  are,  in  the  order  of  their  frequency,  mental  defectives,  epileptics, 
ne'er-do-wells,  psychopaths,  and  syphilitics.  Mental  examinations  are  now 
being  used  at  the  recruit  depots  and  in  the  training  camps  in  the  endeavor 
to  eliminate  as  many  as  possible  of  the  above  types  of  mental  and  moral  defect 
and  psychopathic  inferiority.  "The  volunteers  coming  to  the  recruit  depots 
have  a  large  percentage — 3%  to  5% — of  unfit.  The  national  guard  and  national 
army  have  been  mobilized  for  too  brief  a  period  to  make  it  possible  to  say  what 
their  percentage  will  be.  We  have  watched  with  the  greatest  care  the  officers' 
training  camp.  ...  In  that  fine  body  of  men  .  .  .  the  finest  lot  of 
young  men  in  the  world,  from  1^%  to  2%  are  nervously  unfit  for  war." 

All  the  above  methods  have  been  applied  by  the  Surgeon  General  in  elimina- 
ting the  mentally  and  nervously  unfit  for  service.  For  the  care  and  treatment 
of  cases  of  "shell  shock"  special  hospitals  have  been  built,  special  offices  have 
been  created,  and  a  special  personnel  of  enlisted  men  has  been  collected.  Nurses 
specially  qualified  to  care  for  nervous  patients  are  being  sent  abroad  and  will 
serve  on  the  staffs  of  the  regular  base  hospitals,  the  small  hospitals  and  the  rest 
homes  for  suffering  soldiers. 

Colonel  Bailey  concluded  his  address  with  a  discussion  of  the  many  lessons 
that  the  civil  community  will  learn  from  the  war,  especially  along  the  lines  of 
neurology  and  psychiatry. 

*  Report  of  an  address  delivered  at  the  General  Session  of  the  American  Public  Health 
Association,  Washington,  D.  C,  October  19,  1917. 


101 

Journal  Amer.  med,  assoc.  70:  714,  March  9,  1918.    Mechanism  of 
Shock  (Paris  Letter,  Feb.  7,  1918) 

At  one  of  the  recent  meetings  of  the  Academy  of  Sciences,  Dr.  Marage  dis- 
cussed the  grave  phenomena  observed  among  soldiers  as  the  result  of  the  explo- 
sion of  large  shells.  He  said  that  while  there  was  no  apparent  lesion,  the  wounded 
presented  the  following  symptoms,  all  of  which  might  be  present  in  any  one 
patient:  loss  of  memory,  of  equilibrium,  of  vision,  of  hearing  and  of  speech. 
These  symptoms  disappear  gradually  in  from  six  to  eight  weeks,  or  they  may 
persist  for  j'ears,  and  imless  treated,  they  may  become  permanent.  Marage 
explains  these  symptoms  as  being  due  to  the  effects  produced  by  the  high  ex- 
plosives employed  in  this  war.  It  is  known  that  the  velocity  of  the  sound  wave 
is  333  meters  per  second  under  the  atmospheric  pressure;  but  in  the  neighbor- 
hood of  an  exploding  shell  the  speed  of  the  shock  wave  may  be  as  great  as  2,000 
meters  per  second,  a  velocity  happily  attenuated  very  quickly,  for  even  at  60 
meters  the  velocity  becomes  merely  that  of  sound.  But  in  that  danger  zone  of 
60  meters,  the  pressure  is  increased  as  high,  even,  as  200  kilograms  to  the  square 
centimeter,  but  this  pressure  lasts  only  1  or  2  hundredths  of  a  second.  Further- 
more, in  the  danger  zone  the  increase  of  pressure  is  not  uniform,  and  in  the  zone 
of  action  there  may  be  dead  sectors.  The  intensity  of  these  zones  of  action  is 
unequal,  being  stronger  toward  the  sides  than  toward  the  front  and  rear.  This 
explains  why  soldiers  in  the  same  zone  present  extremely  variable  central  lesions. 
Under  the  influence  of  this  enormous  increase  in  pressure,  the  blood  is  forcibly 
driven  toward  the  center,  hence  toward  the  brain.  This  sudden  tidal  wave  of 
blood  would  be  always  fatal  if  the  capillaries  by  their  resistance  did  not  check  it 
somewhat.  Marage  concludes  from  this  that  it  is  not  by  any  means  always  the 
middle  ear  which  is  the  cause  of  war  deafness,  but  that  the  whole  body  surface 
is  responsible.  The  ear  protectors  are  very  useful  in  certain  cases,  but  unfor- 
tunately they  do  not  protect  against  this  kind  of  deafness. 

Gordon,  Alfred.     The  Problem  of  "Neurotics"  in  Military  Service. 
Med.  rec.  93:  234-37,  Feb.  9,  1918 

A.  Gordon  in  a  practical  article  emphasizes  the  very  great  importance  of  the 
early  recognition  of  this  type  of  man,  and  points  out  the  grave  dangers  of  his 
continuance  in  war  service.  He  draws  accurately  the  picture  of  this  class  of 
cases  which  are  most  liable  to  become  unbalanced  under  severe  mental  or  physi- 
cal strain,  and  the  grave  consequences  of  such  breakdown  to  the  man  and  the 
service.  The  author  suggests  that  a  closer  inspection  of  the  family  and  personal 
history  would  probably  lead  to  the  discovery  before  enlistment  of  large  numbers 
of  these  cases,  and  that  if  such  cases  were  eliminated  before  they  reached  the 
training  camps,  much  expense  to  the  Government  would  be  saved  and  greater 
efficiency  result.  The  author's  suggestions  seem  to  be  of  great  importance. — 
E.  H.  R.,  Bost.  med.  and  surg.  j.  178:  x,  May  9,  1918. 

Journal  Amer.  med.  assoc.  70:866,  March  23,  1918.    War  Tremors 
(Paris  Letter,  Feb.  21,  1918) 

At  one  of  the  recent  meetings  of  the  Societe  de  neurologic,  Drs.  Henry  Meige 
and  Mme.  Benisty  presented  a  number  of  patients  afflicted  with  tremors,  and 
emphasized  particularly  the  clinical  characters  which  permit  of  a  differentiation 
between  tremors  of  organic  origin  and  those  of  a  neuropathic  or  emotional  origin. 
Among  the  organic,  they  insisted  on  the  morphologic  and  physiologic  objective 
characters  of  the  parkinsonian  type,  of  which  they  presentetl  a  characteristic 
example  consecutive  to  traumatism.  They  also  showed  cases  of  nervous  tremors 
the  result  of  wounds  or  of  concussion,  and  also  cases  of  tremors  antedating  the 


102 

war,  occurring  among  emotional  subjects.  They  distinguish,  besides  true  tremor, 
clonic  movements  which  are  sometimes  confounded  with  the  latter,  and  which 
are  the  result  of  certain  lesions  of  the  peduncular  protuberance.  In  the  clinical 
diagnosis  it  is  essential  to  examine  with  care  the  seat  and  the  form  of  the  tremor. 
When  it  is  confined  to  the  fingers  and  is  fine  and  rhythmic,  it  is  nearly  always  of 
organic  origin.  One  frequently  sees  a  nervous  tremor  involving  only  the  flexors 
and  extensors  of  the  wrist,  or  the  pronators  and  supinators  without  any  involve- 
ment of  the  fingers.  When  studying  a  tremor  it  is  essential  to  determine  by 
manual  palpation  the  sensations  experienced  while  mobilizing  parts  of  the  limb. 
The  waxy  flexibility,  flexibilitS  cirreuse,  of  Parkinson's  disease,  is  clearly  distinct 
from  the  cog  wheel  resistance,  resistance  a  crans,  perceptible  in  the  majority  of 
nervous  tremors,  and  evidenced  by  a  succession  of  contractions  and  relaxations, 
more  or  less  brusque,  occurring  at  regular  intervals. 

The  evolution  of  a  tremor  is  also  of  diagnostic  value.  It  may  be  (1)  progressive, 
localized  at  flrst  in  one  member  or  iu  part  of  a  member,  but  progressively  involves 
one  or  more  of  the  other  members.  Parkinson's  disease  belongs  in  this  class.  Or 
the  tremor  may  be  (2)  retrogressive,  generalized  at  first  but  tending  gradually  to 
become  localized  in  one  member  or  part  of  a  member.  This  evolution  is  charac- 
teristic of  tremors  of  neuropathic  origin.  There  is  further  (3)  the  migratory 
tremor,  whose  localization  varies,  as  do  likewise  its  extent  and  time  of  appear- 
ance. The  migration  of  the  tremor  may  occur  spontaneously.  It  can  be  ren- 
dered more  apparent  by  changing  the  position  of  the  member,  or  if  one  or  more 
parts  or  segments  are  immobilized. 

Meige  and  Benisty  also  called  attention  to  the  necessity  of  morphologic  exam- 
ination, wliich  enables  one  to  appreciate  the  state  of  permanent  hypertonicity  of 
certain  persons  with  tremor,  a  phenomenon  to  whose  existence  in  Parkinson's 
disease  Paul  Richet  and  Meige  have  previously  called  attention,  and  which  may 
also  be  seen  in  paratonic  subjects.  It  is  evidently  a  manifestation  of  desequili- 
hration  motrice  congenitale.  Dr.  Tinel,  chef  de  clinique  a  la  Salpetriere,  stated 
that  he  had  observed  several  cases  of  neuropathic  tremor  of  a  member  since  this 
condition  had  been  cured  by  intense  faradic  reeducation.  He  has  also  noted  the 
migration  of  certain  tremors.  The  neuropathic  tremors  are  at  the  same  time 
real,  involuntary,  persisting  during  sleep  and  even  under  the  influence  of  chloral, 
but,  nevertheless,  perfectly  influenced  by  reeducation.  There  exists  in  these 
cases  a  state  of  neuromuscular  hyperexcitability  associated  with  a  persistent 
emotional  state. 

Amer.  med.  24:  306-07,  May  1918.    The  Treatment  of  War  Neuroses 
(London  Letter,  March  26,  1918) 

Two  different  conditions,  wliich  may  be  described  as  neurasthenic  and  hyster- 
oid,  either  of  which  conditions  sometimes  receives  the  name  of  "  shell-shock, "  are 
at  the  present  moment  the  subject  of  the  anxious  attention  of  physicians  and 
psychologists  at  the  front,  in  the  base  hospitals,  and  in  the  various  home  institu- 
tions, general  or  special,  for  the  treatment  of  chronic  cases.  On  the  etiology  of 
many  of  these  cases,  and  therefore  of  their  treatment,  much  difference  of  opinion 
has  been  expressed,  as  is  shown  by  the  fact  that  quite  recently  one  famous  London 
neurologist  said  that  in  his  experience  many  patients  suffering  from  so-called 
"shell-shock"  were  "shell-shy",  while  another  gave  it  as  his  experience  that 
deliberate  malingering  was  very  rare.  The  view  of  the  writer  of  pensions, 
Mr.  J.  Hodge,  has  been  publicly  expressed  that  the  admixture  of  shell-shock  cases 
with  "cheery  chaps"  in  general  hospitals  would  give  good  results,  and  Professor 
Elliot  Smith  of  Manchester  has  demolished  it  with  delightful  scorn.  Such  dif- 
ferences of  opinion  indicate  that  different  advisers  find  different  courses  advisable 
for  the  patients,  for,  while  it  is  obviously  wrong  to  congregate  malingerers  in  any 
large  institution  where  their  form  of  weakness  may  spread  to  other  patients,  it  is 


103 

equally  obvious  that  for  subjects  requiring  real  neurologic  care,  persons  qualified 
to  give  them  that  attention  should  be  in  attendance.  Those  British  authorities 
who  agree  so  far  as  to  acquiesce  in  the  necessity  of  having  neurologic  centers, 
differ  on  one  point,  as  to  the  locality  of  those  centers,  some  seeing  no  harm  in 
keeping  the  patients  in  towns,  and  others  desiring  to  send  them  into  the  quietest 
possible  country  districts.  It  is  clear  that  it  is  easier  to  obtain  a  first-class  scienti- 
fic staff  for  an  institution  in  a  large  urban  center  than  it  ever  could  be  for  homes 
scattered  up  and  down  the  countryside,  a  practical  reason  which  has  to  a  great 
extent  dictated  the  geography  of  the  various  institutions. 

The  question  of  receiving  shell-shock  patients  into  London  institutions  has 
been  complicated  by  the  fact  that  London  is  subjected  to  aerial  bombardment, 
the  effect  of  which  upon  the  shell-shocked  patient  may  well  be  regarded  mth  ap- 
prehension. It  is  undoubted  that  in  some  of  the  hospitals  in  the  London  area  the 
raids  have  an  ill  effect  upon  those  patients,  although  the  amount  of  damage  done 
to  them  seems  to  have  been  considerably  exaggerated,  wliile  the  stories  of  panic 
spreading  from  patient  to  patient  lack  all  authority  and  are  backed  by  no  evi- 
dence. On  the  other  hand,  categorical  statements  have  been  made  by  certain 
medical  officers  that  no  ill  effect  of  any  marked  sort  can  be  observed  among 
the  shell-shocked  patients  on  the  nights  of  German  air  raids,  and  that,  where  in- 
dividual patients  have  shown  signs  of  breakdown,  it  has  been  easy  to  restore  their 
equanimity,  and  noticeably  that  on  later  occasions  in  similar  cricumstances  that 
equanimity  was  preserved.  The  arrangements  for  the  treatment  of  discharged 
soldiers  and  sailors  are  now  made  by  the  Ministry  of  Pensions  and  the  matter  of 
reception  and  treatment  of  cases  of  war  nem"osis  forms  a  subject  to  which  that 
department  is  now  giving  considerable  attention.  But  the  medical  profession 
does  not  feel  wholly  satisfied  with  the  arrangement  made  by  the  ministry  to  keep 
in  touch  with  first-class  scientific  opinion,  and  the  view  has  been  expressed  in  no 
uncertain  terms  that  the  ministry  ought  to  provide  itself  with  an  advisory  com- 
mittee of  general  physicians  and  surgeons,  experts  in  various  special  directions, 
so  that  errors  which  have  certainly  been  committed  in  the  treatment  of  soldiers 
and  sailors  discharged  under  the  heading  of  neurosis  should  for  the  future  be 
avoided. 

Bailey,  Pearce.  Malingering  in  U.  S.  Troops,  Home  Forces,  1917; 
Bulletin  compiled  from  Reports  of  Medical  Officers.  Mil.  surg. 
42:  261-75,  427-49,  March  and  April  1918 

Malingerers  in  a  military  environment  may  be  divided  into  two  groups:  (1) 
those  that  feign  symptoms  with  full  knowledge,  interest  and  responsibility,  and 
(2)  the  constitutionally  inferior  individuals  who  are  never  able  to  face  disagreeable 
situations  without  complaint  and  deceit.  With  the  progress  of  medicine  the 
number  of  cases  of  group  1  has  decreased  whereas  group  2  has  increased  consider- 
ably. "One  surgeon  expresses  himself  as  convinced  'that  in  almost  all  of  the 
cases  in  which  defects  were  simulated  or  exaggerated,  the  patients  were  actually 
defective  either  in  a  lesser  degree  or  in  a  different  affection  or  in  both.  Whether 
the  malingering  took  the  form  of  mental  or  nervous  or  physical  defects  it  was 
based,  in  almost  every  instance,  on  an  actual  unstable  or  defective  mental  state. 

Malingering  is  more  frequent  at  the  National  Army  camps  than  at  the  National 
Guarfl  divisions,  but  even  here  it  has  never  exceeded  1%  of  the  whole  command. 
The  motives  that  lead  men  to  feign  disability  are  varied.  By  far  the  most  com- 
mon purpose  is  to  evade  service,  and  therefore  the  presence  of  malingering  among 
drafted  men  has  been  more  marked  than  among  those  that  have  enlisted.  'J'liere 
are  some  men  who  apply  honestly  for  enlistment,  but  who  later  feign  symptoms 
in  order  to  be  dismissed;  others  apply  with  the  deliberate  purpose  of  being  re- 
jected for  physical  unfitness  so  that  they  may  avoid  being  drafted  into  the  service. 
Every  minor  ailment  is  often  exaggerated  because  the  men  wish  to  avoid  un- 


104 

pleasant  duties.  On  the  other  hand  boys  of  fifteen,  sixteen,  or  seventeen  often 
pass  as  eighteen  or  over  in  order  to  enter  the  service.  Sometimes  men  will 
conceal  disabilities  and  diseases  in  order  to  join  the  army.  This  is  especially 
true  of  alcoholics  and  epileptics.  Often  soldiers  accused  of  delinquency  will  claim 
a  medical  examination  to  obtain  exemption  from  punishment.  Less  frequently 
men  will  try  to  obtain  transfers  to  different  divisions,  such  as  the  Quartermaster's 
Corps  or  the  Medical  Corps  where  they  beheve  the  work  to  be  easier  and  less 
perilous. 

Suggestion  is  an  important  factor  in  maUngering.  This  may  come  from  remote 
sources  such  as  the  idea  of  being  weak  or  delicate  before  entering  the  army  and 
the  probable  breakdown  resulting  from  the  strain  of  army  life,  or  the  symptoms 
may  be  transferred  suggestively  from  one  man  to  another  in  the  same  company. 
To  understand  cases  of  this  kind,  the  medical  officer  must  establish  relations 
with  the  recruits  whereby  the  real  nature  of  the  malingering  is  disclosed. 

There  are  very  few  malingei'ers  of  the  criminal  type.  Most  malmgering  is 
done  in  a  crude  way  and  so  is  easily  detected.  For  the  detection  and  cure  of 
maUngering  the  examining  ofiicer  must  both  recognize  the  self-induced  factitious 
conditions  and  estimate  the  degree  of  exaggeration  in  complaints  of  actual  or 
preexisting  diseases,  conditions  or  injuries.  A  brief  stay  in  the  hospital  is  usually 
sufiicient  to  disclose  the  self-induced  symptoms.  When  there  is  a  suspicion  that 
existing  ailments  are  exaggerated,  the  medical  oflficers  must  decide  whether  or  not 
the  alleged  suffering,  compared  with  conditions  actually  found,  is  beyond  medical 
experience.  After  this  point  is  determined,  the  motives  which  led  to  the  exag- 
geration must  be  discovered.  This  can  be  done  best  by  studying  the  soldier's 
personality,  his  home  and  school  life,  his  business  career,  and  his  own  ideas  con- 
cerning his  health. 

The  various  disabilities  that  are  feigned  may  be  listed  under  (1)  disturbances 
of  vision,  (2)  disturbances  of  hearing,  (3)  general  medical,  (4)  general  surgical, 
(5)  nervous  and  mental  conditions,  (6)  factitious  conditions  including  wounds, 
and  (7)  bed-wetting.  Many  tests  for  the  detection  of  physical  disabilities  are 
described  m  detail.  However,  in  spite  of  the  fact  that  most  malingerers  are 
psychoneurotics,  few  of  them  ever  feign  mental  or  nervous  diseases.  Insanity, 
however,  is  easUy  recognized  as  feigned  by  the  failure  to  produce  any  clinical 
type  or  by  absurd  statements  and  actions.  Mental  defect  is  feigned  frequently, 
for  the  most  part  by  illiterates  and  foreigners,  who,  because  of  their  ignorance 
of  the  language,  feel  that  they  can  display  an  unnecessary  amount  of  stupidity. 
Knowledge  of  the  home  environment,  and,  in  the  case  of  foreigners,  an  inter- 
preter are  necessary  for  their  detection.  The  discovery  of  simulation  and  man- 
agement of  cases  that  complain  of  pain  and  hyperesthesia  is  as  follows:  "Failure 
to  correspond  in  distribution  with  true  clinical  types.  History  often  quite  incon- 
sistent with  type  of  pain  complained  of.  Absence  of  the  ordinary  traces  of  pro- 
longed pain,  and  of  the  other  symptoms  which  usually  accompany  type  of  pain 
complained  of.  When  referred  to  limited  areas,  absence  of  the  sharply  localized 
painful  points  characteristic  of  neuralgias.  Behavior  of  patient  (when  he  thinks 
himself  unobserved)  to  be  carefully  noted."  Tremors  are  frequent  in  the  early 
days  of  training,  as  a  result  of  unusual  exertions.  If  accompanied  by  other 
symptoms  the  etiology  should  be  determined.  Anesthesia  is  frequently  present 
in  neurotic  persons.  Complaint  of  this  condition  however  indicates  malingering 
since  genuine  patients  rarely  realize  its  existence.  "The  most  reliable  means  of 
detection  consists  in  its  failure  to  reproduce  the  clinical  picture  of  the  various 
diseases  in  which  it  occurs,  and  the  faulty  association  with  other  symptoms." 
Epilepsy  is  frequently  imitated  since  it  is  a  common  cause  of  discharge  from  the 
army,  but  the  fits  are  usually  imitated  in  a  clumsy  fashion,  or  when  no  physicians 
are  present.  However  it  is  doubtful  as  to  whether  men  that  can  imitate  grand 
mal  epileptic  attacks  can  be  made  into  desirable  soldiers  or  not.  It  is  probable 
that  they  are  constitutionally  neurotic.    A  verified  history  of  previous  attacks  is 


105 

always  necessary.  In  attacks  of  true  grand  mal,  the  pupil  does  not  react  to  light 
for  a  short  time  after  the  attack,  the  Babinski  reflex  is  present  and  the  knee  jerks 
are  lost.  In  mahngering  the  initial  cyanosis  of  the  epileptic  is  wanting  and  the 
tongue  is  seldom  bitten.  Frothing  at  the  mouth  is  reproduced  by  filling  it  be- 
forehand with  soap  suds.  Hysteria  is  rarely  chosen  by  malingerers  although  it 
is  difficult  to  detect  as  feigned.  "The  symptoms  of  hysteria  never  reproduce 
those  of  organic  disease  but  they  come  closer  to  it  than  is  possible  to  any  con- 
scious simulator,  and  whenever  there  is  a  reasonable  doubt  as  to  whether  a  man 
is  really  pretending  or  not,  the  chances  are  that  a  hysterical  element  is  strongly 
represented  in  the  case."  This  question  comes  up  most  frequently  in  cases  of 
paralysis  and  of  contractures  of  the  muscles  of  the  back.  The  use  of  the  Faradic 
current  usually  proves  or  disproves  the  presence  of  organic  paralysis,  either 
peripheral  or  central  by  determining  the  t  j-pe  of  symptoms  and  the  way  in  which 
they  are  associated.  Cases  in  which  the  back  is  held  stiffly  forward  or  laterally 
may  require  an  X-ray  examination  for  determining  the  absence  or  presence  of 
disease  of  the  vertebrae.  These  contractures  however  are  usually  associated 
with  the  belief  on  the  patient's  part  that  he  has  an  actual  disease  of  the  spine  or 
kidneys  and  clear  up  rapidly  under  the  usual  methods  of  treating  hystero-mahn- 
gerers. 

Pretended  alcohohsm  or  drug  addiction  is  sometimes  made  a  basis  for  exemp- 
tion from  service.  These  cases  are  detected  when,  deprived  of  the  drugs,  they 
show  no  deprivation  phenomena. 

Various  other  conditions  are  artificially  created  or  simulated,  such  as  amputa- 
tions, self-inflicted  wounds,  teeth  extractions,  inflammations  of  the  skin  by  the 
use  of  irritating  chemicals,  retention  of  urine,  etc.  Bed-wetting  is  of  frequent 
occurrence  since  it  is  easy  to  assume,  difficult  to  detect  when  simulated,  and 
often  leads  to  discharge. 

Major  Bailey  closes  his  report  with  a  brief  discussion  of  the  conscientious 
objector. 

Med.  rec.  93:  781,  May  4,  1918.    Convalescent  Homes  for  Neuras- 
thenic Cases  (London  Letter,  April  4,  1918) 

The  Minister  of  Pensions,  Mr.  John  Hodge,  is  finding  himself  in  considerable 
opposition  to  the  best  medical  opinions  in  the  attitude  which  he  has  taken  up 
with  regard  to  the  homes  of  recovery  which  are  being  instituted  for  neurasthenic 
and  shell  shock  cases.  Mr.  Hodge  has  official  medical  opinion  to  rely  upon, 
but  either  this  opinion  is  not  as  well  informed  as  it  should  be  or  he  is  preferring 
to  listen  to  the  popular  view.  The  popular  view  is  that  the  neurasthenic  pa- 
tient requires  cheering  up  by  intermixture  with  other  patients,  and  also  that 
as  his  condition  can  often  be  attributed  to  what  is  vaguely  labeled  "shell  shock", 
it  is  particularly  important  that  the  institution  into  wliich  he  is  received  should 
be  outside  the  area  of  possible  or  probable  air  raids.  Of  course,  no  patients  ought 
to  be  placed  within  a  danger  zone  if  it  is  possible  to  accommodate  them  outside. 
But  there  has  obviously  been  great  exaggeration  of  the  Ul  effects  displayed  by 
the  shell-shocked  patients  after  subjection  to  an  air  raid.  So  far  from  being 
more  agitated  than  any  other  members  of  the  population,  when  judiciously  han- 
dled they  bear  the  ordeal  with  perfect  calm.  A  limited  number  of  neuras- 
thenic cases  may  improve  when  mixed  up  with  a  general  hospital  population. 
Some  also  may  only  require  ordinary  treatment  in  a  convalescent  home,  or  can  be 
boarded  out  as  country  visitors,  or  may  be  added  to  the  population  of  village 
centers,  but  as  a  rule  those  suffering  from  functional  nervous  disorders  require 
special  treatment  which  can  only  be  given  in  special  institutions.  The  scat  tar- 
ing of  neurasthenic  patients  in  various  directions  on  the  chance  that  a  proportion 
of  them  may  get  better  is  a  policy  directly  opposed  to  that  intensive  treatment 
of  disease  which  has  proved  in  every  department  of  surgery  and  medicine  to  be 


106 

the  really  efficient  way  of  dealing  with  the  pathological  results  of  the  war.  The 
War  Office  has  taken  a  better  line  than  Mr.  Hodge,  in  the  opinion  of  real  neuro- 
logists, when  the  military  authorities  issued  a  recommendation  that  all  soldiers 
suffering  from  a  functional  nervous  disorder  should  be  segregated  for  treatment 
into  special  hospitals  immediately  on  their  home  arrival,  and  that  such  hospi- 
tals should  be  staffed  by  medical  officers  interested  in  and  specially  trained  for, 
the  work.  There  is  a  strong  feeling  in  medical  circles  that  the  Ministry  of  Pen- 
sions should  be  provided  with  some  sort  of  advisory  medical  council  so  that  the 
minister  might  be  kept  in  better  touch  with  scientific  medicine.  Undoubtedly 
it  is  a  popular  belief  that  it  does  the  neurasthenic  patient  good  to  be  cheered  up 
by  the  merry  convalescents  from  minor  surgical  injuries,  but  official  support  of 
this  belief  may  produce  feeUngs  of  considerable  anxiety  among  the  relatives  of 
neurasthenic  patients  who  are  receiving  the  proper  treatment  on  intelligent 
segregation  and  individual  scientific  attention. 

Journal  Amer.  med.  assoc.  70: 1554,  May  25,  1918.  Special  Commis- 
sion for  Surveillance  of  Outcome  of  Nervous  and  Mental  Disease 
in  Soldiers  (Paris  Letter,  April  18,  19 18) 

Conforming  to  the  plan  adopted  December,  1917,  at  the  reunion  of  the  chiefs 
of  the  centers  of  neurology  and  psychiatry  and  by  the  Societe  de  neurologic, 
the  undersecretary  of  state  for  the  Service  de  Sante  MUitaire  has  decided  on  the 
creation  of  a  special  commission  for  supervision  of  the  results  of  treatment  of 
nervous  and  mental  disease  in  soldiers.  This  commission  is  charged  with  the 
technical  control  of  the  neurology  and  psychiatry  centers,  and  also  the  solution 
of  medicolegal  questions  in  debatable  and  rebellious  neurologic  or  psychiatric 
cases  (convalescence,  temporary  or  permanent  invaliding,  military  sanctions, 
etc.).  The  committee  is  called  to  functionate  principally  for  cases  treated  in  the 
special  centers  for  functional  reeducation  and  exceptionally  for  other  cases 
which  will  be  submitted  by  the  undersecretary  of  state  for  the  Service  de  Sant6 
Militaire.  As  a  rule,  the  commission  will  examine  on  the  spot  the  cases  referred, 
to  them.  The  commission  is  composed  of  Drs.  Achille  Souques,  medecin  des 
hopitaux  de  Paris,  Ernest  Dupre,  professor  agrege  a  la  Faculte  de  medecine  de 
Paris,  et  medecin  des  hopitaux,  Henri  Claude,  professor  agrege  a  la  Faculte  de 
medecine  de  Paris  et  medecin  des  hopitaux,  and  Dr.  Froment. 

Journal  Amer.  med.  assoc.  70:  1554,  May  25,  1918.  The  Treatment 
of  Shell  Shock  (London  Letter,  April  30,  1918) 

The  large  number  of  men  discharged  from  the  army  because  of  shell  shock 
presents  a  new  problem.  They  have  been  treated  in  a  long  series  of  military 
hospitals,  where  every  effort  has  failed,  and  finally  they  have  been  sent  out  into 
the  world  physically  sound  but  mentally  broken  down,  incapable  of  work  and 
unfit  even  to  go  home  to  their  families.  Like  many  other  new  problems  pre- 
sented by  the  war,  experience  and  energy  have  solved  this  one.  Special  hospitals 
have  been  established  for  the  treatment  of  such  men  with  excellent  results. 
The  patient  is  first  put  to  bed  in  a  room  alone  and  the  physician  brings  mental 
influence  to  bear  on  him,  for  drugs  are  of  little  use.  He  is  encouraged  to  regain 
his  lost  will  power.  The  next  step  is  to  put  him  in  a  room  with  suitable  compan- 
ions and  rouse  his  interest  in  things  outside  himself.  At  first  he  is  very  imso- 
ciable  because  he  has  lost  self  confidence;  but  sooner  or  later  he  begins  to  mix 
with  his  fellows  and  then  plays  billiards,  cards,  or  other  games.  In  the  gymna- 
sium, systematic  exercises  are  then  performed  under  an  instructor.  Various 
forms  of  work,  of  which  carpentry  and  bootmaking  are  the  most  popular,  are 
next  undertaken.  At  first  the  patients  work  only  an  hour  in  the  day,  then  two, 
and  so  on  until  six  hours  are  attained.     Other  trades  taught  are  engineering, 


107 

■electric  light  work,  motor  construction,  and  intensive  gardening.  Two  thirds  of 
the  patients  return  to  their  former  work,  and  one  fourth  are  made  useful  workers 
in  some  other  line.  Thus  complete  recovery  takes  place  in  eleven  out  of  twelve 
cases. 

Sexton,  F.  H.  Vocational  Rehabilitation  in  Canada  of  Soldiers  Suffer- 
ing from  Nervous  Diseases.  Mental  hygiene  2 :  265-76,  April 
1918 

Although  it  was  expected  that  many  men  in  the  armies  would  not  be  able  to 
endure  the  mental  strain  of  war,  hardly  any  one  w^as  prepared  to  find  that  so 
large  a  proportion  of  discharges  would  be  due  to  nervous  troubles.  "In  England 
nearly  20%  of  the  175,000  pensioners  are  suffering  from  functional  nervous 
disease  and  the  greater  part  of  these  have  not  been  actually  wounded.  In 
Canada  over  10%  of  all  the  25,000  men  who  had  returned  up  to  October  1,  1917, 
were  classified  as  mental  cases.  This  category  included  insanity,  shell  shock, 
neurasthenia,  etc.  If  those  who  were  returned  as  over-age,  under-age,  and  for 
duty  are  excluded,  the  mental  cases  represent  15%  of  the  invalids,  and  if  those 
suffering  from  actual  wounds  are  not  counted,  the  mental  cases  constitute  25% 
of  all  those  returned  from  the  Canadian  army  in  England  and  France.  From  a 
purely  military  point  of  view  this  factor  of  war  neurosis  is  liighly  important  where 
so  many  men  have  to  be  discarded  for  mental  causes.  From  an  economic 
standpoint,  the  treatment  of  so  large  a  percentage  of  invalids  in  order  to  rein- 
state them  in  productive  work  is  a  serious  matter." 

During  the  early  part  of  the  war  mental  and  nervous  cases  were  removed 
from  the  front  lines  and  even  sent  to  England  for  treatment,  but  when  German 
submarines  began  to  sink  hospital  ships,  neurological  centers  had  to  be  estab- 
lished in  France.  These  are  usuallj'  situated  in  the  immediate  rear  out  of  range 
of  all  but  the  largest  guns.  "A  special  shell  shock  hospital  is  run  in  conjunction 
with  a  clearing  hospital  in  each  area.  Each  indi\adual  soldier  is  looked  upon  as  a 
separate  case.  .  .  .  The  doctors,  nurses  and  staff  are  all  carefully  selected  for 
their  special  abilities  and  personalities.  The  atmosphere  of  the  institution  is  a 
deliberately  planned  mixture  of  firmness  and  kindness.  It  has  a  mihtary  tang, 
but  is  not  so  impersonal  and  severe  as  the  army.  All  the  staff  are  expected  to 
radiate  optimism  and  cheerfulness.  The  patients  are  kept  as  far  as  possible  from 
introspection.  .  .  .  Quick  recoveries  are  the  rule  and  a  high  percentage  of  the 
men  return  to  the  trenches  inside  of  a  month  or  even  a  fortnight.  An  expert 
French  medical  officer  in  charge  of  one  of  these  centers  reports  that  91%  of  the 
cases  received  in  a  four-month  period  were  sufficiently  recovered  to  send  back 
into  the  fighting  line.     ,     .     . 

"If  the  patients  do  not  show  signs  of  quick  recovery  they  are  sent  to  the  base 
or  to  England.  If  they  are  Canadians  and  will  not  be  fit  again  for  six  months 
they  are  sent  home  for  further  treatment  before  discharge.  ...  If  the  men 
are  suffering  from  a  form  of  mental  disease  that  treatment  will  not  benefit,  they 
are  sent  to  the  hospital  for  the  insane  in  the  province  to  wliich  they  belong. 
The  government  pays  for  their  maintenance  and  if  the  man  is  married,  his  wife 
gets  the  same  pension  for  herself  and  her  cliildren  as  if  her  husband  were  dead. 
If  the  case  is  severe  and  needs  more  careful  diagnosis  and  treatment,  the  man  is 
sent  to  the  Central  Hospital  for  Nervous  Diseases  at  Cobourg,  Ontario.  .  .  . 
From  here,  patients  may  be  discharged  to  hospitals  for  the  insane,  to  regular  con- 
valescent homes,  or  to  civil  life." 

Sexton  quotes  statistics  as  to  types  of  war  neuroses  from  Cobourg  reports. 
"Hydrotherapy  and  electrotherapy  are  used  with  most  gratifying  results,  but 
some  form  of  vocational  training  is  depended  upon  to  build  up  the  will  and  ini- 
tiative of  the  patient.  .  .  .  He  is  first  told  that  his  nervous  disability  does 
not  at  all  unfit  him  for  success  in  some  civilian  occupation,  but  that  it  is  severe 


108 

enough  to  debar  him  from  any  further  military  service.  This  sets  his  mind  at 
rest  about  being  retm-ned  to  the  army,  and  directs  his  attention  to  the  future." 
He  is  then  given  some  hght  occupational  work  upon  which  he  spends  at  first 
only  an  hour  or  two  a  day,  but  the  time  is  gradually  increased  until  he  is  working 
all  day.  Then  he  is  promoted  to  classes  requiring  more  skill  and  effort,  and  so  on. 
Judicious  praise  is  employed,  but  no  "mollycoddling"  is  allowed.  If  the  patient 
is  much  interested  in  liis  work,  very  little  attention  is  paid  by  the  doctors  to  his 
ailments,  so  that  his  mind  may  be  kept  entirely  concerned  with  things  other  than 
his  own  condition.  .  .  .  "When  the  patient  is  fit  to  return  to  civil  life,  he 
goes  back  to  his  own  job,  or  enters  a  course  in  another  institution,  or  else  is  ap- 
prenticed in  industry  to  gain  the  knowledge  and  skill  necessary  for  his  success 
in  some  regular  occupation. 

"The  institutions  most  necessary  for  treatment  of  these  men  are  convalescent 
homes,  not  hospitals.  .  .  .  The  homes  are  usually  situated  near  large  cities 
so  that  expert  medical  services  may  be  secured,  and  each  has  a  capacity  of  from 
300  to  1,000  patients.  In  order  to  make  proper  use  of  the  time  of  the  soldier 
during  the  day,  vocational  training  was  introduced  into  every  home,  and  now  the 
vocational  building  is  an  integi'al  part  of  every  new  building  plan."  At  first  ad- 
mission to  classes  was  voluntary,  but  the  treatment  so  quickly  proved  its  value 
that  after  a  brief  time  vocational  work  was  made  compulsory  for  all  men  not 
excused  as  unfit  by  the  medical  oflBcer.  Instruction  is  given  in  English,  French, 
arithmetic,  stenography,  bookkeeping,  tj^jewriting,  telegraphy,  woodworking, 
shoe  repairing,  mechanical  and  architectural  drawing,  care  and  operation  of 
automobiles,  machine-tool  operating,  electrical  wiring,  gardening,  poultry- 
farming,  etc.  The  daily  program  requires  from  four  to  foin*  and  a  half  hours  of 
attendance.     Each  man  is  allowed  to  make  his  choice  of  classes. 

To  nervous  cases  the  making  of  novelties  and  hand-wrought  jewelry  has 
proved  especially  interesting.  The  articles  made  may  be  kept  by  the  patient 
if  he  pays  for  the  raw  materials,  or  they  may  be  sold  at  reasonable  prices  as  war 
souvenirs.  In  this  way  many  a  patient  has  made  enough  to  serve  as  a  nest  egg 
with  which  to  start  life  again  when  discharged.  Very  few  nervous  patients  can 
be  interested  in  work  requiring  mental  effort;  they  like  best  creative  work  with 
the  hands.  Light  woodworking  and  machine-tool  operation  have  proved 
popular  with,  shell  shock  cases.  A  machine  shop  is  too  noisy  for  most  nervous 
patients,  but  some  have  achieved  great  proficiency  as  macliinists  in  spite  of  this 
drawback.  Farming  is  beneficial  to  those  who  lived  in  the  country  before  the 
war,  but  former  city-dwellers  seem  to  find  the  isolation  and  quiet  routine  of  farm 
life  an  aggravation  rather  than  a  help.  But  no  rules  for  choice  of  occupation  can 
be  formulated.  It  is  necessary  to  find  the  line  of  work  in  which  the  particular 
case  is  most  interested  and  then  to  furnish  instruction  in  it.  Mild  cases  should 
be  directed  toward  recognized  wage-earning  work  as  they  will  thus  the  more 
readily  regain  initiative  and  self-confidence.  Many  cases  have  left  the  conva- 
lescent homes  fitted  to  take  up  work  in  which  they  have  been  more  deeply  in- 
terested and  in  which  they  have  received  greater  remuneration  than  in  their  pre- 
war occupations. 

"The  vocational  training  in  the  convalescent  homes  is  only  incidental  and  sup- 
plementary to  the  medical  treatment.  When  a  man  becomes  an  arrested  case 
he  is  discharged  whether  he  has  finished  a  course  or  not.  If  he  is  then  unable  to 
follow  his  old  trade  successfully  he  is  a  subject  for  vocational  re-education.  He 
is  brought  before  a  Disabled  Soldiers  Training  Board,  composed  of  a  special  med- 
ical officer,  a  vocational  officer,  and  a  layman  who  may  be  an  employer,  a  labor 
organizer,  a  business  man,  a  professional  man,  etc.,  representing  the  public. 
The  man's  desires  and  former  occupation,  together  with  his  disability  are  care- 
fully considered,  and  he  is  advised  in  regard  to  the  vocations  he  may  enter  with 
probability  of  success.  He,  however,  makes  the  choice  liimself  so  that  he  has 
the  greatest  stake  in  his  future  training.     The  effort  is  made  to  keep  him  as  close 


109 

as  possible  to  his  former  work  so  that  his  industrial  experience  and  skill  may  not 
be  altogether  scrapped.  It  is  very  evident  that,  if  possible,  he  should  be  moved 
up  to  a  position  of  greater  skill  and  responsibility  where  he  must  use  his  intelli- 
gence more  and  his  physical  strength  less.  Thi^  is  often  possible,  but  is  not 
usually  the  case.  The  attempt  is  then  made  to  place  him  in  some  occupation  in 
the  same  industry,  but  parallel  w4th  his  former  work  where  his  disability  is  not  a 
serious  handicap.  If  the  central  authorities  at  Ottawa  concur  in  the  recom- 
mendation of  the  Disabled  Soldiers  Training  Board,  the  man  passes  out  of  the 
Army  and  becomes  a  civilian  under  the  control  of  the  Vocational  Branch  of  the 
Military  Hospitals  Commission.  He  receives  special  pay  and  allowances 
running  from  a  mimimum  of  $46.00  a  month,  if  he  is  a  single  man  with  no  depend- 
ents, to  a  maximum  of  $93.00  a  month  in  the  case  of  a  married  man  with  five  or 
more  children  under  sixteen  years  of  age.  This  allows  him  and  his  dep>endents 
to  live  respectably  whUe  he  is  getting  his  training.  He  may  be  sent  to  a  technical 
school,  a  college  of  pharmacy,  an  agricultural  college,  a  business  college,  a  navi- 
gation school,  or  other  special  institution  or  he  may  be  regularly  apprenticed  in 
an  industry.  The  courses  usually  last  six  to  twelve  months  and  are  entirely  free 
of  cost  to  the  man.  He  is  given  an  extra  month's  pay  at  the  end  of  the  course, 
a  position  is  found  for  him,  and  no  deduction  is  made  from  his  pension  because 
of  any  proficiency  or  wage-earning  power  he  has  acquired  at  the  expense  of  the 
government. 

"Thus  Canada  is  trying  to  place  the  disabled  men  on  their  feet  again  in 
civilian  life.  The  attempt  is  being  made  to  eliminate  the  most  pitiful  by- 
product of  war,  the  'old  soldier'.  Having  before  her  the  experience  of  the 
United  States  after  the  Civil  War,  Canada  is  determined  to  have  no  crop  of 
'carpet-baggers',  pension  mongers,  and  government  alms-takers  with  the  con- 
sequent commonplace  fiJching  of  national  funds  and  degeneration  of  civic  hon- 
esty. The  gospel  of  the  busy  life  for  everybody  is  being  preached  and  practiced 
among  the  returned  invalid  soldiers.  Salvation  through  honest  work  applies  to 
the  hero  home  from  France  as  much  as  to  the  mental  defective  or  social  delin- 
quent. The  satisfactory  results  already  achieved  in  Canada  stamp  the  voca- 
tional training  and  re-education  as  the  most  hopeful  activities  in  rehabilitating 
the  men  who  have  placed  their  bodies  and  brains  as  a  barrier  against  the  horrible 
flood  of  German  ideas  that  threatened  to  overflow  the  world,  and  who  have  given 
freely  of  themselves  in  this  glorious  service.  The  goal  is  to  make  the  soldier's 
disability  his  opportunity  and  to  prove  that  his  sacrifice  will  furnish  him  a  staff 
with  whjch  to  support  himself  instead  of  a  millstone  to  drag  him  down." 

N.  Y.  med.  j.  107:  850-51,  May  4,  1918.    The  Mentally  Defective  Sol- 
dier (Editorial) 

For  the  first  time  in  the  lustory  of  warfare  mental  hygiene,  as  practised  among 
soldiers,  lias  been  given  the  prominence  it  deserves,  and,  profiting  by  the  ex- 
perience of  England  and  France  in  the  present  war,  the  Surgeon  General  was 
impelled  to  inaugurate  an  elaborate  organization,  both  in  numbers  and  in  plan, 
to  take  care  of  any  mental  disturbances  detected  in  the  camps  or  among  soldiers 
during  tlie  war.  This  is  a  distinct  innovation  in  medical  army  work,  for  the 
subjects  of  mental  hygiene  and  of  mental  and  nervous  disease  in  general  as  oc- 
curring among  soldiers  in  war  time  were  for  many  reasons  either  shghtly  treated, 
or  neglected  altogether. 

The  outlook  for  those  affected  mentally  during  the  war  is  rather  brighter  than 
among  those  in  civil  life,  and  Lieutenant  Colonel  Pearce  Bailey  (American 
Journal  of  Public  Health,  January,  1918)  finds  the  rate  of  recovery  varying  up 
to  seventy  per  cent,  (Doctor  White's  statistics  of  the  Spanish  war),  as  con- 
trasted with  the  twenty  per  cent  or  twenty-five  per  cent  as  found  among  the 
civilians.     During  peace  the  discharge  rate  from  the  army  of  those  affected  with 


110 

various  psychoses  is  three  men  in  a  thousand,  as  compared  with  six  or  even  tea 
in  a  thousand  during  the  war,  especially  in  expeditionary  wars,  that  is,  wars  in 
foreign  countries,  when  the  ratio  rises  as  high  as  fifty  per  thousand,  as  happened? 
in  the  German  expeditionary  forces  in  the  Boxer  campaign.  Here  evidently 
homesickness  is  an  important  contributory  factor.  Insanity  is  the  most  fre- 
quent cause  for  discharge  in  the  army,  even  more  so  than  tuberculosis,  contrary 
to  the  accepted  belief. 

The  mental  hygiene  work  is  conducted  by  a  staflf  of  qualified  men,  who  re- 
sponded eagerly  to  Surgeon  General  Gorgas's  appeal  for  speciaUsts  issued  in 
April  and  May  of  last  year.  Among  the  cases  they  handle  are,  first  of  all,  the 
mental  defectives,  whose  conduct  in  the  army  may  easily  be  compared  to  the 
behavior  of  backward  and  feebleminded  children  in  school.  Their  mentality 
is  passed  upon  by  new  and  rapid  tests  specially  adapted  to  the  urgency  of  the 
situation.  The  weeding  out  of  these  "stupids"  is  a  matter  of  great  importance 
in  the  morale  of  the  army  during  war,  for  many  a  case  of  apparent  cowardice,, 
for  which  the  unfortvmate  forfeits  his  life,  is  to  be  ascribed  to  feeblemindedness, 
as  the  English  have  found  in  their  experience  during  this  war.  Another  class 
is  the  pampered  son  and  the  ne'er-do-well,  subjects  without  stamina  or  basis 
of  character  or  mind;  the  presence  of  such  is  of  no  value  in  an  army,  and,  once 
found,  they  should  be  gotten  rid  of.  Still  another  t}^e  is  the  individual  who- 
cannot  possibly  be  made  to  fit  within  the  rigid  frame  of  the  collective  discipline 
of  an  army;  divorced  from  his  habitual  way  of  doing  things,  unable  to  orient 
himself  among  the  new  surroundings  for  lack  of  adaptability,  he  soon  collapses 
under  the  strain  and  excitement  of  war  horrors,  and  thus  becomes  a  burden  on 
the  army.  It  is  especially  important  to  keep  in  mind  that  all  such  may  pass 
a  perfect  physical  examination,  as  presumably  very  desirable  soldiers,  and  this 
notwithstanding  may  be  properly  classified  among  the  above  enumerated  cases. 
Even  in  the  officer's  training  camps,  where  are  gathered  some  of  the  finest  speci- 
mens of  young  manhood,  among  candidates  the  two  most  important  qualifi- 
cations of  the  successful  soldier,  the  ability  to  obey  and  the  quality  of  initiative 
and  independence  whenever  the  occasion  demands,  there  are  between  one  per 
cent  to  two  per  cent  nervously  unfit  for  war. 

Amer.  med.  24:265,  May  1918.  The  Reconstruction  of  Men  (Edi- 
torial) 

The  reconstruction  of  men  and  the  industrial  rehabihtation  of  the  nation 
involves  a  new  phase  of  work  for  the  medical  profession.  The  real  results  of 
medical  care  are  not  to  be  gauged  by  the  physical  restoration  of  the  individual,. 
but  in  terms  of  his  psychologic  and  industrial  restoration.  A  new  type  of  med- 
ical work  will  be  developed  combining  medical  experience,  educational  ability,  a 
knowledge  of  the  psychology  of  work  and  workers,  an  understanding  of  the 
nature  and  strains  of  various  industries,  together  with  a  high  degree  of  educational 
resourcefulness.  The  occupational  therapeutist  will  become  a  prominent  factor 
in  the  future  development  of  the  program  for  rehabilita.ting  those  disabled  by 
war.  Unfortunately,  inadequate  attention  has  been  given  to  the  relation  of 
this  problem  to  those  crippled  in  the  struggle  for  existence,  those  who  have  suf- 
fered from  the  all  too  numerous  accidents  which  have  characterized  our  industrial 
development. 

The  place  of  occupational  therapy  in  the  treatment  of  neurasthenia  and 
psychoses  has  been  recognized  and  considerable  progress  has  been  made  in  this 
direction.  The  problems  of  occupation  involved  as  a  result  of  bhndness,  deaf- 
ness, epilepsy,  tuberculosis  and  similar  handicapping  defects  and  diseases  have 
received  constructive  consideration  and  moderate  attempts  have  been  made  to- 
secure  the  adjustments  after  due  training  required  by  such  physical  incapacities. 
A  broader  view  must  now  be  taken,  and  the  occupational  therapeutist  is  already 


Ill 

in  demand  with  a  supply  so  limited  as  to  require  the  immediate  institution  of 
training  courses  to  remedy  the  lack. 

The  economic  returns  of  rehabihtation  are  the  ones  which  are  usually  urged 
and  stressed  by  those  interested  in  the  organization  under  federal  auspices  of  a 
reeducational  program.  From  the  public  health  standpoint,  equally  valuable 
results  are  to  be  attained  as  a  result  of  the  strengthening  of  national  vitahty. 
Gross  handicaps,  unfitting  for  employment,  are  responsible  for  the  reduction  of 
power  and  vitality.  Industrial  incapacity,  with  decreased  economic  rewards, 
results  in  lower  standards  of  living,  with  consequent  limitation  of  physical,  men- 
tal and  moral  welfare.  The  health-giving  environment  depends  upon  an  ade- 
quate living  wage.  Rehabilitation  is  a  health  problem  of  no  mean  proportions, 
and  should  engage  the  serious  attention  of  the  medical  profession,  not  merely  in 
connection  with  war  injuries,  but  with  those  arising  in  every  phase  of  civil  and 
industrial  life. 

Pilgrim,  Charles  W.    The  State  Hospitals  and  the  War.    N.  Y.  State 
hosp.  quar.  3:  223-24,  May  1918 

The  statistics  of  the  hospitals  for  the  insane  in  New  York  State  for  the  forty- 
fom"  months  before  the  war  showed  29,316  admissions;  while  in  the  forty-four 
months  that  have  elapsed  since  the  declaration  of  war  there  have  been  33,311 
admissions.  This  was  a  marked  increase,  and,  as  a  majority  of  the  new  cases 
were  of  the  dementia  praecox  and  manic-depressive  variety,  it  was  only  fair  to 
assume  that  the  stress  and  excitement  of  war  times  was  the  cause.  Another 
interesting  fact  is  that  the  admissions  showed  a  marked  increase  in  recurrent 
cases.  It  was  also  noticed  that  many  cases  occurred  among  old  people  who  had 
delusions  of  a  depressing  character,  such  as  that  the  end  of  the  world  was  ap- 
proaching, that  everything  was  going  wTong,  etc.,  such  as  would  be  caused  by 
the  present  troublous  times.  Another  reason  for  the  increased  admissions  might 
be  that  many  people  have  gone  into  new  employment  where  the  work  has  been 
more  strenuous  and  where  they  have  made  a  great  deal  more  money  and  have 
lived  very  different  lives. 


INDEX  OF  AUTHORS   OF  BOOKS  AND  ARTICLES  ABSTRACTED 


Agostini,  Cesare,  56 
Anderson,  John  E.,  87 
Auer,  E.  Murray,  73 

Babinski,  J.,  26 
Bailey,  Pearce,  100,  103 
Barre,  J.-A.,  23,  25 
Binswanger,  Otto,  45 
Boisseau,  J.,  23,  25 
Buschau,  George,  29 

Campbell,  Kenneth,  9 
Cheyrou,  24 
Collie,  John,  10 
Crinon,  23 
Crouzon,  0.,  25 

Damaye,  Henri,  24 

Farrar.  Clarence  B.,  73 
Ferrand,  Jean,  19 
Forster,  Frederick  C,  13 
Froment,  J.,  26 

Gatti,  L.,  57 
Gordon,  Alfred,  101 
Green,  Edith  M.  N.,  9 
Guillain,  Georges,  23,  25 

Hammond,  Graeme  M.,  83 
Hartmann,  Fritz,  41 
Hoffmann,  Rudolph,  47 
Hoven,  22 
HUbner,  A.  H.,  34 
Hunt,  J.  Ramsay,  84 

Jolly,  P.,  33 

Jones,  A.  Bassett,  13 

Kastan,  Max,  41 

Landau,  21 

Llewellyn,  Llewellyn  J.,  13 

Lowy,  Max,  49 

MacCurdy,  John  Thomson,  75 


Maitland,  E.  P.,  9 
Mann,  Ludwig,  46 
Marburg,  Otto,  38 
Marchand,  L.,  19 
Mauger,  N.,  25 
Mayer,  Alfred  G.,  82 
Mendel,  Kurt,  32 
Meyer,  Robert,  51 
Meyer,  S.,  50 
Mingazzini,  G.,  55 
Mott,  Frederick  W.,  13 

Neymann,  Clarence  A.,  79^ 
Nonne,  Max,  48 
Nordlund,  H.,  69 

Oelsnitz,[M.  d',  23,  25 

Pilgrim,  Charles  W.,  Ill 
Pitres,  A.,  19 

Redard,  Paolo,  56 
Redlich,  Emil,  37 
Riebeth,  44 
Roussy,  Gustave,  23 

Salmon,  Thomas  William,  80,  83,  86, 

88,92 
Sandro,  D.  de,  56 
Savage,  George  H.,  14 
Schultz,  J.  H.,  51 
Seppilli,  G.,  56 
Sexton,  F.  H.,  107 
Soukhanoff,  S.  A.,  65 

Turner,  William  Aldren,  11 

Van  der  Hoeven,  H.,  61 
Viets,  Henry,  12 

Westphal,  A.,  34 
Weyert,  30 
Wcygandt,  W.,  48 
Wolfsohn,  Julian  M,,  14 
Wollenberg,  R.,  43 

Yerkes,  Robert  Mearns,  80 


113 


INDEX  OF  SUBJECTS 


Alcoholism,  22,  23,  30,  33,  86,  37,  49, 

50,94 
Anesthesia,  90 
Anxiety    states.     See   War   neuroses; 

War   psychoneuroses 
Asthenia,  24,  25.     See  also  Etiology, 

fatigue 
Auditory  disturbances,  47,  101 

B 

Barany  test,  51 
Blood  pressure,  9,  10 
Brain  injuries,  38,  39,  55 
British  literature,  7 

C 

Care.     See  Treatment 

Classification,  88 

Clinical  studies,  35 

Concussion.     See  Etiology,  explosives 

Contractures,  23,  25,  26,  5Q 

Conversion  hysteria.     See  Hysteria 

D 

Delinquency,    military,    36,    42,     43. 

See  also  Malingering 
Dementia  precox,  22,  31,  33,  42,  94 
Diagnosis,  14,  31,  32,  48,  51,  77,  89,  90. 

See    also    Malingering;    Organic 

changes 
Dreams,  9,  10,  37 

E 
English  literature.     See  British  litera- 
ture 
Epilepsy,  23,  32,  56,  57,  74,  94 
Etiology,  19,  22,  24,  29,  34,  41,  44,  45, 
46,  47,  50,  73,  75,  88,  89,  96,  97. 
See  also  Alcoholism ;  Brain  injuries; 
Clinical   studies;   Nerve   injuries; 
Organic  changes;  Predisposition; 
Syphilis;    and    names    of    signs, 
symptoms  and  diseases 
emotion.  13,  29,  97.     See  also  Etiol- 
ogy, fear 
explosives,  35,  37,  50,  82,  88,  88,  101 
fatigue,   75,   84,   85,   86.     -S^;*   also 

Asthenia 
fear,  73 


French  literature,  17 

G 

Gait  disturbances,  90.  See  also  Par- 
alyses 

General  paralysis.  See  Paralysis,  gen- 
eral 

German  literature,  27 

German  Red  Cross,  79 

Granatfieher,  79 

H 

Hospitals.     See  Military  hospitals 
Hysteria,  25,  26,  33,  36,  45,  46,  50,  56, 
75,  76,  77,  90 


Indemnity  and  pensions,  12,  36 
Insanity.     See  Mental  diseases,  etc.; 
War  psychoses;  and  names  of  dis- 
eases 
Italian  literature,  53 

M 

Malingering,  13,  22,  86,  38,  69,  76,  77, 
79,  90,  91,  102,  103,  104,  105 

Manic  depressive  psychoses,  35,  36,  94 

Mechanism,  47,  88 

Mental  defectives  in  armies,  42,  79,  80, 
93,94,110 

Mental  diseases  in  armies,  61,  88,  92, 
93,  109,  110.     See  also  Unfitness 
for  service;  War  psychoses;  and 
names  of  diseases 
in  the  civilian  population.  111 

Military  hospitals,  80.     See  also  Rec- 
ommendations for  the  U.  S.  Army 

N 
Nerve  injuries,  38,  39, 40,  41.     See  also 

Brain  injuries 
Netherlands,  literature  of,  5d 
Neurasthenia,  10,  13,  33,  38,  44,  56. 

See  also  War  neuroses;  War  psy- 

choneuroses 
Neuropsychiatric  service,  24,  106 
United  States,  86,  96,  100.     Sec  also 

Recommendations  for  the  U.  S. 

Army 


ii/; 


116 


O 

Organic  changes,  96,  97.  See  also 
Brain  injuries;  Nerve  injuries; 
Pathology 


Paralyses,  19,  34,  46,  50,  90.  See  also 
Paralysis,  general;  Pseudoparesis 

Paralysis,  general,  81,  82,  94.  See 
also  Syphilis 

Paranoia,  32 

Pathology,  20.  See  also  Clinical  studies ; 
Mechanism;  Organic  changes; 
Physiological  changes;  and  names 
of  signs,  symptoms  and  diseases 

Pensions.  See  Indemnity  and  pen- 
sions 

Physiological  changes,  23.  See  also 
Asthenia;  Etiology,  fatigue;  Path- 
ology 

Predisposition,  15,  22, 31,  35,  38, 43,  44, 
46,  47,  51,  73,  89.  See  also  Psy- 
chopathic constitution 

Prevention,  12,  13,  30,  36,  78,  79,  94, 
99,  101.  See  also  Psychology  ap- 
plied to  military  problems;  Un- 
fitness for  service 

Prognosis,  37,  47,  48,  50,  51,  99 

Pseudoparesis,  84,  85,  86 

Psychology  applied  to  military  prob- 
lems, 10,  80,  81,  83,  87 

Psychopathic  constitution,  32,  33, 
42, 49,  94.     See  also  Predisposition 

R 

Recommendations  for  the  U.  S,  Army, 

94,95 
Reconstruction,  14,  22,  107,  108,  109, 

110,111 
Recoverability,  19, 56,  94, 107 
Russian  literature,  65 


Scandinavian  literature,  67 

Shell    shock.     See    Organic    changes; 

War  neuroses;  War  psychoneuro- 

ses;  War  psychoses 
Simulation.     See  Malingering 
Soldier's  heart,  78 
Speech  disorders,  56,  89 
Statistics,  15,  22,  24,  25,  26,  29,  30,  31, 

32,  49,  73,  93 
Symptomatology,  13, 14, 19,  29, 30,  32, 

33,  34,  35,  44,  45,  46,  49,  50,  51, 


75,  76,  77,  85,  89,  90.  See  also 
Clinical  studies;  Organic  changes; 
Physiological  changes;  and  names 
of  signs,  symptoms  and  diseases 
Syphilis,  74.  See  also  Paralysis,  gen- 
eral 


Tachycardia,  25 
Temperature,  9 
Tests.     See    Psychology    applied    to 

military  problems;  Prevention 
Transportation,  33 

Traumatic  neuroses,  29,  35,  37,  38. 
See  also  Hysteria;  War  neuroses 
Treatment,  10,  11,  12,  23,  33,  34,  44, 
47,  48,  49,  50,  51,  73,  75,  76,  77, 
78,  79,  91,  98,  99,  102,  103,  105, 
106.  See  also  Clinical  studies; 
Military  hospitals;  Neuropsychia- 
tric  service;  Recommendations 
for  the  U.  S.  Army;  Reconstruc- 
tion 

diet,  24, 38 

electricity,  11,  38,  75,  92.  See  also 
Treatment,  reeducation 

etherization,  5Q 

hydrotherapy,  24, 44, 75, 92 

hypnotism,  48, 49,  91,  99 

isolation,  11,33,38,73 

isolation,  "psychic,"  21 

medicine,  10, 14,  24,  76 

occupation  and  recreation,  12,  14, 
22,  43,  44,  75,  76,  78,  92,  106,  107 
See  also  Reconstruction 

psychoanalysis,  11 

psychotherapy,  11,  12,  14,  26,  34, 
38,  46,  47,  56,  73,  76,  77.  See  also 
Treatment,  hypnotism;  Treat- 
ment, reeducation 

reeducation,  19,  20,  21,  41,  75,  77, 
78,  91,  92,  99.  See  also  Treat- 
ment, psychotherapy 

rest,  14,  40,  73,  76,  80 

segregation,  11,  31 

surgery,  38,  39,  40,  55 

swimming,  92 
Tremors,  101,  102 

U 

Unfitness  for  service,  83,  84.  See  also 
Prevention;  Psychology  applied 
to  military  problems 

United  States,  literature  of,  71 

Urinary  disturbances,  25 


117 


Visual  disturbances,  9,  89 


W 

War  neuroses,  34,  75,  76,  77,  78,  80, 
88,  89,  90,  91,  92,  98,  99,  100. 
See  also  Clinical  studies;  Neuras- 


thenia; Traumatic  neuroses;  and 
names  of  signs  and  symptoms 

War  psychoneuroses,  13,  65.  See  also 
Clinical  studies;  Hysteria;  and 
names  of  signs  and  symptoms 

War  psychoses,  22,  29,  30,  33,  34,  48, 
49,50,56,74,93.  See  afeo  Clinical 
studies;  and  names  of  signs, 
symptoms  and  diseases 


Annex 


034!^  B812 

suppl,i 
Brown 

furopsychiatrjr  and  the  war  • , , 


Ani^ 


